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NURS363 - Practice of Nursing IV > Week 4: Alteration in Nutrition > Flashcards

Week 4: Alteration in Nutrition Flashcards

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1
Q

Factors that affect nutrition

A
  1. Insufficient intake of nutrients
  2. Altered ability to use ingested nutrients
  3. Increased metabolic demand
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2
Q

What are some examples of altered ability to use ingestied nutrients?

A

dentures

do they have physical access to food

disease processes impairing client ability to maintain nutriting like ulcerative colitis and chrons disease

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3
Q

Nursing Interventions for Altered Nutrition

A

Assess for s/s of malnutrition

Monitor oral intake/calorie count

Dietary Consuly

Speech Consult (Swallow eval)

Small, frequent meals

Encourage significant other to bring in fav foods and be present during meals

Manage enteral and parenteral nutrition

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4
Q

What are two very important things to view in the lab results regarding altered nutrition

A

Albumin and Prealbumin Levels

Albumin levels indicate long term pt protein levels

Prealbumin indicates short term pt protein levels

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5
Q

What is an example of something that may make the pt. not want to eat that is not N/V

A

Metallic taste in their mouth from their medications

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6
Q

Examples of Diets

A 
NPO
Clear Liquid (No Residue)
Full Liquid
Thickened Liquid 
SOft or Pureed
Restrictive and Therapeutic Diets
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7
Q

Examples of what can be eaten on a clear liquid diet

A

apple juice

tea

broth

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8
Q

Examples of what can be eaten on a full liquid diet

A

ice cream

creamed soup

pudding

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9
Q

Why have a thickened liquid diet

A

to prevent choking and aspiration

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10
Q

Why have a soft or pureed diet

A

it is easier to chew

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11
Q

examples of Restrictive or therapeutic diets

A

NAS

Cardiac

Renal

Diabetic

High Fiber

Low Residue

Low Cholesterol

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12
Q

What other things can be included in diet/feedings other than the type of diet itself?

A

Nutritional supplements (ensure, boost)

enteral feeding (osmolite, jevity)

parenteral feedings (PPN, TPN)

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13
Q

Paretneral Nutrition

A

nutrition via an IV

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14
Q

Enteral Nutrition

A

nutrition via a tube

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15
Q

GI Intubation

A

suction or feeding via a tube that can be made of many materials like rubber or polyurethane

the tubes are variable in insertion size, length, and lumen amount

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16
Q

What is GI tube size (diameter) measured in

A

French

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17
Q

The larger the french size…

A

the larger the diameter

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18
Q

Gastric Salem Sump tubes have ___ lumen

A

2

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19
Q

GI tubes are measured in what unit

A

centimeters

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20
Q

Most GI tubes are radiopaque, why?

A

So they can be visualized on X Ray

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21
Q

Reasons for doing GI Intubation

A

Decompression

Aspiration

Lavage

Administer

Diagnose

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22
Q

The most common reason for GI Intubation is ___

A

decompression

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23
Q

Decompression GI Intubation

A

Removing gas or fluid build up (removed often from bowel obstructions or can be used to control GI bleeding or prevent emesis (N/V))

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24
Q

Decompression tubes will need…

A

to be hooked to the wall for suction

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25
Q

Aspiration GI Intubation

A

removal of substances by suction

often done to obtain a specimen of gastric content

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26
Q

Lavage GI Intubation

A

A way to wash out or cleanse the stomach - having your stomach pumped is an example and it can remove any toxic substances

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27
Q

Administration GI Intubation

A

Used to give medications or tube feedings

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28
Q

Diagnosis GI Intubation

A

GI tubing and system can be intubated in order to use an endoscope or other method to diagnose a GI disorder

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29
Q

You would use a tube no larger than ___ french for tube feedings. Why?

A

12 French

You do not want to feed too fast and at the volume a feeding tube does it may be too much at once so the french should be smaller or equal to 12

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30
Q

Orogastric Tube

A

Tube inserted through the mouth into the stomach

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31
Q

Nasogastric Tube

A

NG Tube

Tube inserted through the nose into the stomach

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32
Q

The end point for an orogastric and nasogastric tube is the ___

A

stomach

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33
Q

Gastric tubes are often inserted where

A

In the ER, ICU, or post short term surgery

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34
Q

What is compromised when using an orogastric or nasogastric tube

A

The Lower Esophageal Sphincter

This leads to it always being kept open so pt is at risk for aspiration and gastric irritation from gastric fluids if they get into the esophagus

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35
Q

Levin Tube has ___ lumen

A

1

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36
Q

Salem Sump Tube has ___ lumen

A

2

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37
Q

Dobhoff Tube has __ lumen

A

3

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38
Q

How does the Dobhoff tube differ from the levin or salem sump

A

it is much longer so it bypasses the stomach and goes right into the intestines

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39
Q

Never inject anything into what area of a tube

A

the blue port

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40
Q

Why do some tubes have more than 1 lumen with air potentially going through them?

A

Ex: Salem Sump

If there is air going through it it will stop the tube from sticking to the stomach wall

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41
Q

Dobhoff Tube

A

a longer enteral feeding tube that goes all the way to the intestines

it has a weighter tungsten tip and a guide wire for placement

are often placed in a fluoroscopy lab and a provider is there helping get the tip to where it needs to be

3 lumen

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42
Q

What is the reason behind enteric tubes likenasoduodenal tubes, nasojejunal tubes, gastostomy tubes, and jejunostomy tubes?

A

Provide nutrients (tube feedings) fluids, and medications

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43
Q

Nasoduodenal Tube

A

Goes through the nose to the duodenum

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44
Q

Nasojejunal Tube

A

goes through the nose to the jejunum

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45
Q

What is the nurse’s role during intestinal tube placement

A

NOT to place or remove intestinal tubes, but to assist in insertion at GI lab and fluoroscopy

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46
Q

Why are intestinal tubes like nasoduodenal and Nasojejunal tubes often not useable for 24-48 hours?

A

the doctor will place it at the tip of the stomach adn allow peristalsis to take the tube the rest of the way to the location

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47
Q

Naso-tubes are often short term (__ weeks)- while long term more likely uses ___ or ___

A

4 weeks; gastostomy or PEG tubes

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48
Q

Enteral nutrition longer than ___ weeks needs a long term enteral feeding option

A

4 weeks

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49
Q

What are some examples of long term enteral feeding tubes

A

Gastrostomy

Jejunostomy

PEG Tube

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50
Q

Gastrostomy/Jejunostomy are made via what

A

intrabdominal surgery requiring anesthesia where the stomach wall is brought to surface, a tunnel is made, and a permanent stoma is created (in jejunostomy its the jejunum coming to surface)

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51
Q

PEG/PEJ Tube

A

This long term enteral feeding establishes a mean to provide nutrition to the patient to the abdominal wall WITHOUT intra-abdominal surgery
It is done via endoscopic procedure (Percutaneous endoscopic gastrostomy or jejunostomy)

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52
Q

How does the provider make the PEG/PEJ Tube

A

Provider goes through the mouth down to the esophagus and stomach and out through the abdominal wall through the stomach and makes an outlet where a tube is then inserted for feeding

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53
Q

What are some common risks/nursing diagnosis for PEG and Ostomies

A

Invasive Procedures

Risk for Bleeding

Risk for Infection

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54
Q

What is important to note about the tube of a PEG/PEJ compared to an ostomy

A

the PEG/PEJ has not created stoma, so if the tube is removed you have to call the provider immediately since the hole can close in 4 hours !

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55
Q

What are some example nursing diagnoses for enteral nutrition

A

imbalanced nutrition: less than body requirements

risk for infection r/t presence of wound and tube

risk for impaired skin integrity at tube insertion site

disturbed body image r/t presence of tube

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56
Q

What is some example objective/subjective data to gather for nutritional assessment/enteral feeding

A

lab work (albumin)

mucosa moist or not

dehydration

BMI < height and daily weights

I&O

regular diet - is this normal, how many times a day do you eat, nutrition (mouth to butt)

bowel movements

VS

WBC

assess sites and drainage with COCA REEDA

yeast infection risk from dark moist tube inside

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57
Q

Goals for Altered Nutrition and Enteral Feeding

A

achieve nutritional requirements

prevent infection

maintain integrity

adjust to body image

prevent complications

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58
Q

How often should a feeding tube be cleansed

A

every shift at least

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59
Q

Upon evaluation, what nutritional aspects should be looked at

A

attain weight

do they tolerate tube feeding

bowel movements

normal plasma protein level

glucose

V&M

electrolyte balance

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60
Q

Parenteral Nutrition

A

nutrients via IV

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61
Q

When is parenteral nutrition used

A

when the GI tract is not working (or post abdominal aortic aneurysm or other traumatic GI region repair for 5-7 days)

62
Q

How many liters do TPN/PPN bags usually have

A

1-3 L of fluid

63
Q

Why is TPN fluids often covered

A

because they need to not be exposed to light

64
Q

How long is TPN/PPN run for and when are fat emulsions or lipids infused?

A

Run over 24 hours; fat emulsions or lipids are infused simultaneously but not for 24 hours

65
Q

Central Method of Parenteral Nutrition

A

Central line or PICC for TPN

66
Q

Peripheral Method of Parenteral Nutrition

A

Peripheral IV access

67
Q

What is important to keep in mind when using the peripheral method rather than central for TPN/PPN

A

If TPN is done peripherally, DEXCTROSE LESS THAN 10% must be used because the higher dextrose can cause phlebitis that only works centrally

This is also a major reason why central is preferable

68
Q

How long is peripheral parenteral access compared to central

A

Peripheral = short term - 5 to 7 days or as short as 3

Central can be good for up to 6 weeks

69
Q

How long can PICC lines stay in for

A

60 months to a year - it is a port that can be under their chest wall for life

70
Q

What are some indications for TPNO

A

Insufficient oral or enteral intake

Impaired ability to ingest or absorb food orally or enterally

Patient unwilling or unable to ingest adequate nutrients orally or enterally

prolonged preoperative and postoperative nutritional needs

71
Q

What is important to do before giving PN infusion

A

check for “cracked solution” which is separation with an oily appearance or precipitate appearing as white crystals - if present do not use

72
Q

Nursing Diagnoses for parenteral nutrition

A

imbalanced nutrition - less than body requirements related to inadequate oral intake of nutrients

risk for infection related to contamination of the central catheter site or infusion line

risk for imbalanced fluid volume related to altered infusion rate

risk for activity intolerance related to restrictions because of the presence of IV access device

73
Q

Goals for PN

A

optimal nutrition

absence of infection

adequate fluid volume

optimal level of activity

self care knowledge and skill

absence of complicationbs

74
Q

Common complications of PN

A

pneumothorax

air embolism

clotted or displaced catheter

sepsis

hyperglycemia

rebound hypoglycemia

fluid overload

75
Q

What are some things to evaluate and see with PN

A

maintains nutrition

absence of catheter infection

hydration

WNL activity

prevents complication

demonstrates skills

76
Q

Air emboli can occur in PN due to

A

flushing the line

77
Q

Nursing Process for TPN

A
  1. Use infusion pump
  2. Do not change rate quickly
  3. monitor blood glc levels
  4. in absence of PN, use D10
  5. catheter and site care
  6. monitor electrolyte levels
  7. monitor fluid balance indicators
  8. patient teachiong and support
78
Q

Indicators of fluid balance

A

I&O

weighing patient daily

s/s of dehydration or fluid overload

79
Q

Overall Process with NG Tubes

A
  1. prep patient
  2. insert tube
  3. confirm placement
  4. clear tube obstruction
  5. monitor patient
  6. provide oral and nasal hygiene
  7. monitor and manage complications
  8. remove the tube
80
Q

In order to prep the patient for NG tube insertion what should the nurse do

A
  1. Explain the purpose - especially if they are vomiting (to remove contents)
  2. Explain the procedure such as how gagging is common during placement and setup a signal to stop if needed
81
Q

Steps for Inserting NG Tube

A
  1. Confirm provider order and ID patient
  2. measure
  3. sit them upright with a protective barrier
  4. numb nares
  5. lubricate
  6. tilt head up then down
  7. swallow
  8. inspect
  9. attach
82
Q

When inserting an NG tube, choose which nare?

A

the larger and clearer one

83
Q

Always use ___ soluble lubricant

A

water

84
Q

What is the process once actually inserting the NG tube

A

Feel tension at nasopharynx junction –> tilt their head back AND have them take sips of water —> have them swallow –> inspect back of throat, telemetry monitoring, coughing or resp distress signs

85
Q

What ways can NG tube insertion go

A
  1. into stomach
  2. coil out of the mouth (wrong)
  3. lung (very wrong)
86
Q

How do you measure the NG Tube

A

Measure from tip of the ear to the nose and then nose to xiphoid process - 10-15 cm hopefully is in the stomach

87
Q

Before hooking up an NG tube for decompression, what is the gold standard to be done

A

getting a CXR for placement

88
Q

How to secure the NG tube to the patient

A

Use split tape over the nose –> measure NG tube outside the patient and mark, initial, date length of the tube outside and chart and document –> notify provider if ever different

89
Q

Ways to check NG tube placement post-CXR

A
  1. Check tube length outside
  2. check aspirate color
  3. pull aspirate out and look at color
  4. pH measurement
  5. air auscultation
90
Q

What sort of aspirate may be seen from the NG tube

A

clear - intestinal fluid

cloudy, green, brown, tan - gastric fluid

clear - respiratory fluid

see how two are similar color

91
Q

Placement of the NG tube should be checked how often

A

every 4 hours or every shift based on orders and policy

for cont feedings its often every 4 hours

92
Q

When aspirating, flushing, or drawing from a tube always use at least a ___cc syringe

A

30 cc

93
Q

How does aspirate pH differ based on whether it is gastric, intestinal, or respiratory

A

gastric - 1-4 or 5

intestinal - >6

resp - >7

94
Q

Air Auscultation

A

unreliable and rarer method of checking tube placement by flushing air and then auscultating to find where you hear it

95
Q

Adv and Disadv of CXR to check for Tube Placement

A

Adv: Most Accurate

Disadv: Costly, Increased Rad. exposure

96
Q

Adv and Disadv of Measured Exposed Tubing for Tube Placement

A

Adv: Easy and Cheap

Disadv - does not rule out migration to resp. system

97
Q

Adv and Disadv of Aspirate Color for Tube Placement

A

Adv - easy and cheap, good to distinguish between gastric and intestinal

disadv - does not completely rule out resp. placement since both resp and intestinal secretions can be clear, and it is not appropriate for cont. feedings

98
Q

Adv and Disadv of pH of aspirate for tube placement

A

Adv: Good to distinguish between gastric v intestinal

Disadv: does not completely rule out resp placement, Antacids/gastric resection/ grossly bloody samples/cont tube feedings all alter pH, pH monitoring equipment not universally available

99
Q

Adv and Disadv of Air Auscultation for tube placement

A

Adv: Easy and cheap

Disadv: questionable accuracy, may hear whooshing sound but tube can still be in resp tract

100
Q

What are some routine care things to do regarding an NG tube after placement?

A
  1. assess skin routinely for breakdown (especially around nose every day or 3 days) - tube presses on nair and can cause skin tears
  2. flush and irrigate tube to assure patency every 4 hours or based on policy
  3. assess nauseousness and how they feel
  4. keeping pt head of bed up since lower eso sphincter is compromised - high fowlers or high as possible to prevent aspiration
  5. check bowel sounds, I&O and flatus status
101
Q

The most important assessment tool for an NG tube patient is

A

LOOKING AT THEM (if LOC or resp changes occur its very concerning)

102
Q

Why do we flush the tube every 4 hours with saline or water

A

decompression moves gastric contents which can be viscous and clogging the tube or it could be from protein coagulation from feedings

103
Q

When passing by the room of an NG tube patient what should be seen

A

suction felt out of the tube and seeing things moving into the canister through the tube - if they are not moving or the pt feels unwell you want to flush and confirm placement

104
Q

What care is very important with a tube

A

oral and nasal hygiene / oral care

105
Q

NG tubes make people…

A

mouth breathers (so their mucous membranes will be dry and they need good oral hygiene)

106
Q

Ways to provide good NG tube oral care

A

give lip bomb, chapstick, ice chips as ordered and document

inspect skin and mouth daily

change tape daily and prn

moisten mucosa

proper oral hygiene like brushing swabs

107
Q

Aside from oral care, what are some other nursing management things to do for an NG tube

A

check bowel sounds and flatus

line reconciliation

documentation: strict I&O and color/odor/consistency/amount

avoid tension on tube

108
Q

what is the only thing keeping an NG tube in place

A

a little tape! can come out easily

109
Q

An NG or OG tube suction is usually at ___ mmHG

A

-30

110
Q

What should be done prior to NG/OG tube removal

A

Check provider order

assess gi system

gather supplies

wash hands

confirm pt ID

explain procedure

provide privacy

position in semi fowlers

drape barrier across chest

use gloves

111
Q

What is the first step of NG tube removal

A

Clamp Test

112
Q

Clamp Test

A

Done over 6 hours - you let them know the tube is being discontinued and hope they are saying they are hungry and want to eat

Disconnect from suction and clamp NG tube –> Listen to bowel sounds x4 and hear normoactive sounds hopefully –> come back in 2 hours and listen again x4 and check for NV as well as residuals then return them to the stomach and flush with 30 cc of water/saline –> leave for another 2 hours and continue this process until 6 hours with no NV or increase in residuals

113
Q

What to do once the clamp test is done for removal of the tube

A
  1. Flush with 30 mL of air/saline
  2. Untape the tube
  3. clamp tube and disconnect from anything
  4. have them hold their breath as you coil the tube around a gloved hand and pull it out
  5. for the first 6-8 inches pull gently and slowly followed by rapidly for the remainder
  6. never pull hard if resistance is felt - normally resistance should NOT be felt
  7. watch for splatter and wear goggles then perform oral hygiene and start the ordered liquid diet
114
Q

Enteral Feedings

A

Tube Feeding - long term nutrition

115
Q

How do enteral formulas differ

A

they differ depending on disease processes and metabolic needs - so you work with a dietician to decide

116
Q

3 top priorities (and the secret 4th) for Balanced Nutrition and Enteral Formula characteristics are what?

A
  1. Nutrients (protein, carbs, fat, vitamins, and minerals)
  2. Calories
  3. Fiber
  4. Osmolality
117
Q

What is the bodies normal Osmolality

A

300 mOsm/kg

118
Q

What can an enteral formula of osmolality higher than 300 mOsm/kg (too higher) lead to

A

dumping syndrome

119
Q

Types of Enteral Nutrition Infusions

A

Bolus: Drip and Gravity

Continuous Infusion

Cyclic

120
Q

Syringes for tubing should always be…

A

30 cc or higher

121
Q

Bolus Infusions via gravity is about ___ mL over _____ minutes

A

500 mL over 10-15 minutes (and pt holds the tube up above the stomach)

122
Q

Bolus drip infusions are boluses given over ___ minutes

A

30

123
Q

How do continuous infusions differ from bolus ones

A

they are often given as a much slower rate and are done via pump

124
Q

Cyclic Infusion

A

infusion given at night often with supplements as to not disturb ADLs

125
Q

What should be done if a patient can eat

A

dietary consult

126
Q

What should be done if a patient cannot eat and has a non fxnal GI system

A

TPN

127
Q

What should be done if the patient cannot eat, has a functional GI tract but is a high aspiration risk

A

Nasoenteric or Jejunostomy Tube –> cont. feedings (slower rate so lower risk)

128
Q

What should be done if a patient cannot eat, has a functional GI tract but is a low aspiration risk

A

NG tube, Gastrostomy or PEG –> intermittent feedings

129
Q

What sort of methods allow continuous feedings

A

nasoenteric or jejunostomy tube (go to intestines)

130
Q

What sort of methods allows intermittent feedings

A

NG tube, gastrostomy, or PEG (all go to the stomach)

131
Q

Open v Closed Enteral Nutrition Systems

A

Open - Top is opened and cans of tube feeding or jevity are poured in

Closed - spiking with tubing that is prefilled is added to IV

132
Q

What type of enteral nutrition system is more likely to be contaminated? How long can these be hung then?

A

open ; 4 hours maximum

133
Q

Check enteral residuals every __ hours

A

4

134
Q

Potential Complications of Enteral Nutrition

A

Diarrhea

NV

Gas, bloating, cramping

Dumping syndrome

Aspiration pneumonia

tube displacement

tube obstruction

nasopharyngeal irritation

hyperglycemia

dehydration

135
Q

What should be done if residuals draws up 200 cc?

A

first think if thats normal for the patient –> reinstall it back into the stomach –> monitor and check again in 4 hours

If you get residuals that are 200 mL + for 2 consecutive times then you call provider

136
Q

What should be done if residuals draws up 350 cc +

A

stop tube feedings and call provider

137
Q

Dumping Syndrome

A

physiologic response to rapid emptying of gastric contents into small intestines

138
Q

S/S of Dumping Syndrome

A

nausea

weakness

sweating

palpitation

syncope

and possible diarrhea

139
Q

What factors should be considered for assessment with enteral nutrition

A

factors or illnesses that increases metabolic needs

hydration and fluid needs

renal function and electrolyte status

medications

assess mobility and metabolic needs

assessing HF needs, renal disease, BUN and Cr

assess tolerance, residual, administer water, do not mix medications with feedings, HOB 30-45 degrees during feeding and one hour after

140
Q

How should meds be given through a tube

A

crush them and give them one at a time with flushing between pills -wait 30 min to return to

141
Q

Reglin

A

increases GI motility and gets peristalsis happening

142
Q

Important nursing considerations for PEG, G tubes, and J Tubes

A

skin care

teaching self care

body image and coping

tube dislodgement

referrals

143
Q

What begins in the hospital prior to discharge

A

promoting home, community based, and transitional care

144
Q

To move/discharge tube patients home, what should be done before

A

be medically stable and successfully tolerating 60-70% of the feeding regimen

capable of self care or have caregiver willing to assume the responsibility

have access to supplies and an interest in learning how to administer tube feedings

referrals to home, community based, or transitional care is essential as well as patient education

145
Q

A nasally placed feeding tube should stay in place for no more than ____ weeks before being replaced with a new tube

A

4 weeks

146
Q

When administering continuous or cyclic tube feedings, a primary nursing responsibility is preventing ___ pneumonia

A

aspiration

147
Q

T/F: The most commonly used single lumen nasogastric tube is the gastric (Salem) pump

A

False

148
Q

T/F: Visualizing the placement of a nasogastric or nasoenteric tube on X Ray (radiograph) is the only definitive way to verify its locations

A

True

149
Q

T/F: When administering oral medications to a patient receiving tube feedings, medications may be crushed and mixed with the feeding formula

A

False

150
Q

Which of the following are appropriate interventions to prevent potential complications from aspiration?

Check tube placement
Elevate HOB at least 30 degrees during feeding and for one hour afterward.
Place  patient in supine position
Prepare rapid infusion of formula via syringe bolus delivery
Give  small, frequent feedings
Give larger feedings less often
Increase sedation level of patient
Avoid over sedation of patient
Check residual volume per policy
A

Check Tube Placement

Elevate HOB

Give Small Frequent Feedings

Avoid Over sedation of Patient

Check residual volume per policy

151
Q

What are the appropriate interventions to prevent potential complications from a clogged feeding tube”?

Flush tube before and after feeding every ___ hours during continuous feeding and after withdrawing aspirate. Install ___ mL water with 50 mL or 60 mL syringe

A

every 4 hours; install 30 mL of water with 50 mL or 60 mL syringe

NURS363 - Practice of Nursing IV (17 decks)

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