Week 2 Flashcards
Exam 1
When someone is admitted, what do we assume about the person?
When someone is admitted, we assume they are at a nutritional risk.
All critically ill patients are assumed to be at nutritional risk
All critically ill patients are assumed to be at nutritional risk
Around what percent?
≈ 50% on admission to the hospital
What is an important part of overall care plan for patient?
Nutritional support is an important part of overall care plan
Utilization of Nutrients
What organs or organ parts are involved?
Duodenum
Jejunem
Ileum
Colon
Pancreas
Liver
Gallbladder
Utilization of Nutrients
Duodenum: What does it do? What empties here?
Pancreas and liver empty here
Absorbs minerals
Utilization of Nutrients
Jejunum: What occurs here?
Glucose and water-soluble vitamins absorbed
Utilization of Nutrients
Ileum: What occurs here?
Protein broken down and absorbed
Absorbs fat-soluble vitamins
Utilization of Nutrients
Colon: What is formed here? What is absorbed?
Vitamin K formed
Absorbs Na+ and K+
Water reabsorbed
Absorption of short-chain fatty acids
Utilization of Nutrients
Pancreas: What does it do?
Secretes digestive enzymes
Utilization of Nutrients
Liver: What does it do?
Multiple functions like detoxification
Utilization of Nutrients
Gallbladder: What does it do?
Assists in emulsifying fats
Nutritional Assessment:
What does it provide a baseline for?
Provides baseline subjective and objective data regarding nutritional status
Nutritional Assessment:
What does it determine and identify and establish?
Determines nutritional risk factors
Identifies nutritional deficits
Identifies medical, psychosocial, and socioeconomic factors
Establishes nutritional needs
Nutritional Assessment:
What should be considered?
CONSIDER:
access to healthy food, Meals-on-Wheels, lack of support, mobility, & transportation, social isolation, lower income, poorly fitting dentures or missing teeth
Nutritional Assessment
Subjective and objective data in ICU patient
Gag reflex
Dysphagia
Adequate dentition
Oral mucosa
Hydration status
Patient’s medical history
Malabsorption syndrome
Laboratory values
Input and output
Daily weight
Nutritional Therapy Goal: What is it?
Goal is nutritional support consistent with metabolic needs and disease process while avoiding complications
Nutritional Therapy Goal:
What kind of patient requires nutritional support?
Any patient who cannot meet needs orally for 3 or more days requires nutritional support:
Nutritional Therapy Goal:
Any patient who cannot meet needs orally for 3 or more days requires nutritional support:
What are examples of this type of patient?
Diminished cognition
Sedation
Endotracheal intubation
Post-Stroke: impaired swallowing
Nutritional Therapy Goal:
Referral to Nutritionist: What does a nutritionist do?
Patient’s calorie, protein, and fluid needs
Intake targets
Route of administration
Nutritional Therapy Goal
Set measurable short- and long-term goals
What are examples of these types of goals?
Weight gain
Stable laboratory values: pre-albumin, albumin, transferrin
Enteral Nutrition: What is it?
Delivery of nutrients to gastrointestinal (GI) tract
What is the preferred method of feeding people who are at nutritional risk?
Enteral Nutrition- Delivery of nutrients to gastrointestinal (GI) tract
Why is the enteral nutrition the preferred method of feeding people who are at nutritional risk?
Lower risk of infection
Less expensive
Enteral Nutrition
What is the long term nutrition?
Long-term nutrition: PEG or jejunostomy
Enteral Nutrition
What type of tubing goes through the GI tract?
All types of tubing goes through the GI tract.
Guidelines for Enteral Feeding
Short-term enteral feeding includes:
Nasogastric route
Nasoduodenal route
Nasojejunal
Guidelines for Enteral Feeding
Long-term enteral feeding includes:
Gastrostomy tube
Jejunostomy tube
Placing Nasoenteric Tubes:
Who is it placed by?
Placed by skilled nurses or physicians
Placing Nasoenteric Tubes:
When placing, what do they follow?
Follow institutional policy.
Placing Nasoenteric Tubes:
How does the measurement work?
Measure the distance from the tip of the nose, to the earlobe, to the tip of the xiphoid process.
Placing Nasoenteric Tubes:
What kind of things are used to insert the tube?
Topical anesthetic or water-soluble lubricant
Placing Nasoenteric Tubes:
How should the patient be positioned?
Place the patient in high Fowler’s position and flex the patient’s head (if not contraindicated).
Placing Nasoenteric Tubes:
What should be lubricated?
Lubricated tip
Placing Nasoenteric Tubes
What should you ask the patient to do?
Ask the patient to swallow repeatedly.
Placing Nasoenteric Tubes
How should you advance the tube?
Turn the patient to the right lateral decubitus position with the head of the bed at a 30- to 45-degree angle to advance the tube.
Placing Nasoenteric Tubes
Why do you need the patient cooperation?
You ask the patient to swallow so the tube doesn’t go in the trachea.- You need patient’s cooperation
Confirming Placement
What should you measure?
What should you auscultate?
What should you visualize?
Measurement of tube length
Auscultate placement LUQ
Visual assessment of aspirate
pH measurement of aspirate
Confirming Placement:
What is the gold standard for confirming initial tube placement before initiating feeding?
Abdominal radiograph is the gold standard for confirming initial tube placement before initiating feeding.
Securing the Nasogastric Tube:
What should you consider?
Consider mobility
Patient LOC, state of agitation.
Securing the Nasogastric Tube:
What must be auscultated?
Auscultate placement Q 4 hrs., pre-medications
Securing the Nasogastric Tube:
What must tube be pinned to?
Wrap adhesive tape around tube and pin to pt gown. DO NOT PIN TO PILLOW CASE
Securing the Nasogastric Tube:
What must be retaped?
Re-tape if wet
Enterostomal Feeding and Feeding Tubes
Indicated when:
Therapy will last a month or more
Nasal route is contraindicated
Patient has impaired swallowing
Oropharynx, larynx are obstructed
Percutaneous esophageal gastrostomy (PEG) tube
How should HOB be?
HOB at least 30 degrees
Percutaneous esophageal gastrostomy (PEG) tube
What should be done around the insertion site?
Assess & clean skin around insertion site
Percutaneous esophageal gastrostomy (PEG) tube
What must be done after each intermittent feeding?
Flush NG tube or PEG after each intermittent feeding
Percutaneous esophageal gastrostomy (PEG) tube
How should meds be given?
Crush medications except enteric coated tablets.
Percutaneous esophageal gastrostomy (PEG) tube
How should Time-release tablets be given?
Time-release tablets: some can be opened; cannot be crushed because doing so may release too much drug too quickly (overdose); always check with pharmacist if in question
Tolerance of Enteral Nutrition
Presence of bowel sounds in four quadrants, as determined by auscultation
Presence of bowel motility or bowel movements
Palpation of a soft abdomen
Percussion of the abdomen revealing tympanic findings
Signs of Intolerance of _____.
Nausea or vomiting
Absent bowel sounds
Abdominal distension
Cramping
Diarrhea
Tolerance of Enteral Nutrition
How long should you listen for bowel sounds?
You need to listen to FIVE minutes.
Complications of Enteral Nutrition
Gastrointestinal
Mechanical
Metabolic
Infectious
Complications of Enteral Nutrition
Gastrointestinal
High residuals,
nausea,
vomiting,
bloating,
diarrhea,
constipation
Complications of Enteral Nutrition
Mechanical
Tube dislodgment,
clogging
Complications of Enteral Nutrition
Metabolic
Electrolyte imbalances,
hyperglycemia
Complications of Enteral Nutrition
Infectious
Aspiration
Complications of Enteral Nutrition
Management:
Observe residuals.
Watch for signs and symptoms of gastric intolerance.
Do not add medications to enteral formulas.
Complications of Enteral Nutrition
Management:
Why do you need to aspirate the contents? What amount is normal to aspirate someone?
It is important to aspirate the contents to see if they are tolerating the feeding.
When aspirating someone, upto 250mL is normal. But it also depends on the facility.
Parenteral Nutrition (PN):
When is this indicated?
Oral or enteral nutrition is not possible.
Absorption or function of the gastrointestinal tract is not sufficient.
Parenteral Nutrition Formulas
May be either Total Parenteral Nutrition (TPN) or Peripheral Parenteral Nutrition(PPN)
Parenteral Nutrition Formulas
What does TPN require?
TPN requires a central line (save one port)
Parenteral Nutrition Formulas
What must be done for each ingredient? What kind of solution is used?
Verify orders for each ingredient
Refrigerated solution
Parenteral Nutrition Formulas
What should not be done in this line?
Do not inject any med into this line
Parenteral Nutrition Formulas
How much solution should be in this line?
2-3 L of solution in 24 hours
Parenteral Nutrition Formulas
What kind of filter should be used?
Using a filter (1.2 micron particulate filter)
Parenteral Nutrition Formulas
What should be inspected? Why?
Inspect solution for clarity and precipitate
Parenteral Nutrition Formulas
You can’t withdraw blood from the same port you are feeding, why?
You can’t withdraw blood in the same port you are feeding because it will lead to improper results and contamination can occur.
Parenteral Nutrition Formulas
How are you administering TPN?
If you are administering TPN- usually by central line.
Parenteral Nutrition Formulas
How are you administering PPN?
If you are administering PPN- peripheral line is smaller compared to central line.
Central Methods: Triple Lumen Catheter
What must be done before starting TPN?
Confirm placement of catheter tip by x-ray before starting TPN
Central Methods: Triple Lumen Catheter
What kind of catheters may be used? What cannot be done with the catheter?
Single, double, or triple lumen catheters may be used
Blood can not be drawn from catheter
Central Methods: Triple Lumen Catheter
What is used for long term?
TPN
Central Methods: Triple Lumen Catheter
What is used for short term?
PPN- because it is a smaller vein
Peripheral Parenteral Nutrition (PPN):
How is it infused?
PPN is infused into smaller peripheral vein via peripherally inserted central catheter (PICC).
Peripheral Parenteral Nutrition (PPN)
How long is it used as nutritional support?
Short-term nutritional support (7 to 10 days)
Peripheral Parenteral Nutrition (PPN)
How to supplement?
Supplement during transitional phases to enteral or oral nutrition
Peripheral Parenteral Nutrition (PPN)
Concentrations of PPN formulas must not exceed what? Why?
Concentrations of PPN formulas must not exceed 900 mOsm/L to minimize risk of phlebitis.
Complications of Catheter & Parenteral Nutrition
Pneumothorax during insertion
Air embolism during insertion
Clotted catheter line
Catheter displacement
Catheter contamination
Sepsis
Hyperglycemia: supplement with insulin
Fluid overload
Rebound hypoglycemia
Complications of Catheter & Parenteral Nutrition
Since hyperglycemia can occur, what must be done?
Hyperglycemia: supplement with insulin
Complications of Catheter & Parenteral Nutrition
What is pneumothorax?
Pneumothorax- air in the chest cavity which could lead to a collapsed lung.
Complications of Catheter & Parenteral Nutrition
Rebound hyperglycemia:
Rebound hyperglycemia- happens right after a person is fed. Could be minutes or hours.
Nursing Interventions
What should you check insertion site for?
Check insertion site for leakage; bloody purulent drainage; a kinked catheter;
skin reactions such as inflammation, redness, swelling or tenderness
Nursing Interventions
What should you assess for?
Assess for signs of dehydration
Obtaining initial “dry weight” and weekly weights
Vital signs
Intake and output
Assess enteral tube and IV catheter.
Assess abdominal and abdominal girth.
Bowel sounds
Nursing Interventions
What should you provide for the family and patient?
Provide information and emotional support to the patient and family.
