Week 4: Alteration in Nutrition Flashcards
Factors that affect nutrition
- Insufficient intake of nutrients
- Altered ability to use ingested nutrients
- Increased metabolic demand
What are some examples of altered ability to use ingestied nutrients?
dentures
do they have physical access to food
disease processes impairing client ability to maintain nutriting like ulcerative colitis and chrons disease
Nursing Interventions for Altered Nutrition
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
What are two very important things to view in the lab results regarding altered nutrition
Albumin and Prealbumin Levels
Albumin levels indicate long term pt protein levels
Prealbumin indicates short term pt protein levels
What is an example of something that may make the pt. not want to eat that is not N/V
Metallic taste in their mouth from their medications
Examples of Diets
NPO Clear Liquid (No Residue) Full Liquid Thickened Liquid SOft or Pureed Restrictive and Therapeutic Diets
Examples of what can be eaten on a clear liquid diet
apple juice
tea
broth
Examples of what can be eaten on a full liquid diet
ice cream
creamed soup
pudding
Why have a thickened liquid diet
to prevent choking and aspiration
Why have a soft or pureed diet
it is easier to chew
examples of Restrictive or therapeutic diets
NAS
Cardiac
Renal
Diabetic
High Fiber
Low Residue
Low Cholesterol
What other things can be included in diet/feedings other than the type of diet itself?
Nutritional supplements (ensure, boost)
enteral feeding (osmolite, jevity)
parenteral feedings (PPN, TPN)
Paretneral Nutrition
nutrition via an IV
Enteral Nutrition
nutrition via a tube
GI Intubation
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
What is GI tube size (diameter) measured in
French
The larger the french size…
the larger the diameter
Gastric Salem Sump tubes have ___ lumen
2
GI tubes are measured in what unit
centimeters
Most GI tubes are radiopaque, why?
So they can be visualized on X Ray
Reasons for doing GI Intubation
Decompression
Aspiration
Lavage
Administer
Diagnose
The most common reason for GI Intubation is ___
decompression
Decompression GI Intubation
Removing gas or fluid build up (removed often from bowel obstructions or can be used to control GI bleeding or prevent emesis (N/V))
Decompression tubes will need…
to be hooked to the wall for suction
Aspiration GI Intubation
removal of substances by suction
often done to obtain a specimen of gastric content
Lavage GI Intubation
A way to wash out or cleanse the stomach - having your stomach pumped is an example and it can remove any toxic substances
Administration GI Intubation
Used to give medications or tube feedings
Diagnosis GI Intubation
GI tubing and system can be intubated in order to use an endoscope or other method to diagnose a GI disorder
You would use a tube no larger than ___ french for tube feedings. Why?
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
Orogastric Tube
Tube inserted through the mouth into the stomach
Nasogastric Tube
NG Tube
Tube inserted through the nose into the stomach
The end point for an orogastric and nasogastric tube is the ___
stomach
Gastric tubes are often inserted where
In the ER, ICU, or post short term surgery
What is compromised when using an orogastric or nasogastric tube
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
Levin Tube has ___ lumen
1
Salem Sump Tube has ___ lumen
2
Dobhoff Tube has __ lumen
3
How does the Dobhoff tube differ from the levin or salem sump
it is much longer so it bypasses the stomach and goes right into the intestines
Never inject anything into what area of a tube
the blue port
Why do some tubes have more than 1 lumen with air potentially going through them?
Ex: Salem Sump
If there is air going through it it will stop the tube from sticking to the stomach wall
Dobhoff Tube
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
What is the reason behind enteric tubes likenasoduodenal tubes, nasojejunal tubes, gastostomy tubes, and jejunostomy tubes?
Provide nutrients (tube feedings) fluids, and medications
Nasoduodenal Tube
Goes through the nose to the duodenum
Nasojejunal Tube
goes through the nose to the jejunum
What is the nurse’s role during intestinal tube placement
NOT to place or remove intestinal tubes, but to assist in insertion at GI lab and fluoroscopy
Why are intestinal tubes like nasoduodenal and Nasojejunal tubes often not useable for 24-48 hours?
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
Naso-tubes are often short term (__ weeks)- while long term more likely uses ___ or ___
4 weeks; gastostomy or PEG tubes
Enteral nutrition longer than ___ weeks needs a long term enteral feeding option
4 weeks
What are some examples of long term enteral feeding tubes
Gastrostomy
Jejunostomy
PEG Tube
Gastrostomy/Jejunostomy are made via what
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)
PEG/PEJ Tube
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)
How does the provider make the PEG/PEJ Tube
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
What are some common risks/nursing diagnosis for PEG and Ostomies
Invasive Procedures
Risk for Bleeding
Risk for Infection
What is important to note about the tube of a PEG/PEJ compared to an ostomy
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 !
What are some example nursing diagnoses for enteral nutrition
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
What is some example objective/subjective data to gather for nutritional assessment/enteral feeding
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
Goals for Altered Nutrition and Enteral Feeding
achieve nutritional requirements
prevent infection
maintain integrity
adjust to body image
prevent complications
How often should a feeding tube be cleansed
every shift at least
Upon evaluation, what nutritional aspects should be looked at
attain weight
do they tolerate tube feeding
bowel movements
normal plasma protein level
glucose
V&M
electrolyte balance
Parenteral Nutrition
nutrients via IV
When is parenteral nutrition used
when the GI tract is not working (or post abdominal aortic aneurysm or other traumatic GI region repair for 5-7 days)
How many liters do TPN/PPN bags usually have
1-3 L of fluid
Why is TPN fluids often covered
because they need to not be exposed to light
How long is TPN/PPN run for and when are fat emulsions or lipids infused?
Run over 24 hours; fat emulsions or lipids are infused simultaneously but not for 24 hours
Central Method of Parenteral Nutrition
Central line or PICC for TPN
Peripheral Method of Parenteral Nutrition
Peripheral IV access
What is important to keep in mind when using the peripheral method rather than central for TPN/PPN
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
How long is peripheral parenteral access compared to central
Peripheral = short term - 5 to 7 days or as short as 3
Central can be good for up to 6 weeks
How long can PICC lines stay in for
60 months to a year - it is a port that can be under their chest wall for life
What are some indications for TPNO
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
What is important to do before giving PN infusion
check for “cracked solution” which is separation with an oily appearance or precipitate appearing as white crystals - if present do not use
Nursing Diagnoses for parenteral nutrition
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
Goals for PN
optimal nutrition
absence of infection
adequate fluid volume
optimal level of activity
self care knowledge and skill
absence of complicationbs
Common complications of PN
pneumothorax
air embolism
clotted or displaced catheter
sepsis
hyperglycemia
rebound hypoglycemia
fluid overload
What are some things to evaluate and see with PN
maintains nutrition
absence of catheter infection
hydration
WNL activity
prevents complication
demonstrates skills
Air emboli can occur in PN due to
flushing the line
Nursing Process for TPN
- Use infusion pump
- Do not change rate quickly
- monitor blood glc levels
- in absence of PN, use D10
- catheter and site care
- monitor electrolyte levels
- monitor fluid balance indicators
- patient teachiong and support
Indicators of fluid balance
I&O
weighing patient daily
s/s of dehydration or fluid overload
Overall Process with NG Tubes
- prep patient
- insert tube
- confirm placement
- clear tube obstruction
- monitor patient
- provide oral and nasal hygiene
- monitor and manage complications
- remove the tube
In order to prep the patient for NG tube insertion what should the nurse do
- Explain the purpose - especially if they are vomiting (to remove contents)
- Explain the procedure such as how gagging is common during placement and setup a signal to stop if needed
Steps for Inserting NG Tube
- Confirm provider order and ID patient
- measure
- sit them upright with a protective barrier
- numb nares
- lubricate
- tilt head up then down
- swallow
- inspect
- attach
When inserting an NG tube, choose which nare?
the larger and clearer one
Always use ___ soluble lubricant
water
What is the process once actually inserting the NG tube
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
What ways can NG tube insertion go
- into stomach
- coil out of the mouth (wrong)
- lung (very wrong)
How do you measure the NG Tube
Measure from tip of the ear to the nose and then nose to xiphoid process - 10-15 cm hopefully is in the stomach
Before hooking up an NG tube for decompression, what is the gold standard to be done
getting a CXR for placement
How to secure the NG tube to the patient
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
Ways to check NG tube placement post-CXR
- Check tube length outside
- check aspirate color
- pull aspirate out and look at color
- pH measurement
- air auscultation
What sort of aspirate may be seen from the NG tube
clear - intestinal fluid
cloudy, green, brown, tan - gastric fluid
clear - respiratory fluid
see how two are similar color
Placement of the NG tube should be checked how often
every 4 hours or every shift based on orders and policy
for cont feedings its often every 4 hours
When aspirating, flushing, or drawing from a tube always use at least a ___cc syringe
30 cc
How does aspirate pH differ based on whether it is gastric, intestinal, or respiratory
gastric - 1-4 or 5
intestinal - >6
resp - >7
Air Auscultation
unreliable and rarer method of checking tube placement by flushing air and then auscultating to find where you hear it
Adv and Disadv of CXR to check for Tube Placement
Adv: Most Accurate
Disadv: Costly, Increased Rad. exposure
Adv and Disadv of Measured Exposed Tubing for Tube Placement
Adv: Easy and Cheap
Disadv - does not rule out migration to resp. system
Adv and Disadv of Aspirate Color for Tube Placement
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
Adv and Disadv of pH of aspirate for tube placement
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
Adv and Disadv of Air Auscultation for tube placement
Adv: Easy and cheap
Disadv: questionable accuracy, may hear whooshing sound but tube can still be in resp tract
What are some routine care things to do regarding an NG tube after placement?
- assess skin routinely for breakdown (especially around nose every day or 3 days) - tube presses on nair and can cause skin tears
- flush and irrigate tube to assure patency every 4 hours or based on policy
- assess nauseousness and how they feel
- keeping pt head of bed up since lower eso sphincter is compromised - high fowlers or high as possible to prevent aspiration
- check bowel sounds, I&O and flatus status
The most important assessment tool for an NG tube patient is
LOOKING AT THEM (if LOC or resp changes occur its very concerning)
Why do we flush the tube every 4 hours with saline or water
decompression moves gastric contents which can be viscous and clogging the tube or it could be from protein coagulation from feedings
When passing by the room of an NG tube patient what should be seen
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
What care is very important with a tube
oral and nasal hygiene / oral care
NG tubes make people…
mouth breathers (so their mucous membranes will be dry and they need good oral hygiene)
Ways to provide good NG tube oral care
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
Aside from oral care, what are some other nursing management things to do for an NG tube
check bowel sounds and flatus
line reconciliation
documentation: strict I&O and color/odor/consistency/amount
avoid tension on tube
what is the only thing keeping an NG tube in place
a little tape! can come out easily
An NG or OG tube suction is usually at ___ mmHG
-30
What should be done prior to NG/OG tube removal
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
What is the first step of NG tube removal
Clamp Test
Clamp Test
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
What to do once the clamp test is done for removal of the tube
- Flush with 30 mL of air/saline
- Untape the tube
- clamp tube and disconnect from anything
- have them hold their breath as you coil the tube around a gloved hand and pull it out
- for the first 6-8 inches pull gently and slowly followed by rapidly for the remainder
- never pull hard if resistance is felt - normally resistance should NOT be felt
- watch for splatter and wear goggles then perform oral hygiene and start the ordered liquid diet
Enteral Feedings
Tube Feeding - long term nutrition
How do enteral formulas differ
they differ depending on disease processes and metabolic needs - so you work with a dietician to decide
3 top priorities (and the secret 4th) for Balanced Nutrition and Enteral Formula characteristics are what?
- Nutrients (protein, carbs, fat, vitamins, and minerals)
- Calories
- Fiber
- Osmolality
What is the bodies normal Osmolality
300 mOsm/kg
What can an enteral formula of osmolality higher than 300 mOsm/kg (too higher) lead to
dumping syndrome
Types of Enteral Nutrition Infusions
Bolus: Drip and Gravity
Continuous Infusion
Cyclic
Syringes for tubing should always be…
30 cc or higher
Bolus Infusions via gravity is about ___ mL over _____ minutes
500 mL over 10-15 minutes (and pt holds the tube up above the stomach)
Bolus drip infusions are boluses given over ___ minutes
30
How do continuous infusions differ from bolus ones
they are often given as a much slower rate and are done via pump
Cyclic Infusion
infusion given at night often with supplements as to not disturb ADLs
What should be done if a patient can eat
dietary consult
What should be done if a patient cannot eat and has a non fxnal GI system
TPN
What should be done if the patient cannot eat, has a functional GI tract but is a high aspiration risk
Nasoenteric or Jejunostomy Tube –> cont. feedings (slower rate so lower risk)
What should be done if a patient cannot eat, has a functional GI tract but is a low aspiration risk
NG tube, Gastrostomy or PEG –> intermittent feedings
What sort of methods allow continuous feedings
nasoenteric or jejunostomy tube (go to intestines)
What sort of methods allows intermittent feedings
NG tube, gastrostomy, or PEG (all go to the stomach)
Open v Closed Enteral Nutrition Systems
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
What type of enteral nutrition system is more likely to be contaminated? How long can these be hung then?
open ; 4 hours maximum
Check enteral residuals every __ hours
4
Potential Complications of Enteral Nutrition
Diarrhea
NV
Gas, bloating, cramping
Dumping syndrome
Aspiration pneumonia
tube displacement
tube obstruction
nasopharyngeal irritation
hyperglycemia
dehydration
What should be done if residuals draws up 200 cc?
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
What should be done if residuals draws up 350 cc +
stop tube feedings and call provider
Dumping Syndrome
physiologic response to rapid emptying of gastric contents into small intestines
S/S of Dumping Syndrome
nausea
weakness
sweating
palpitation
syncope
and possible diarrhea
What factors should be considered for assessment with enteral nutrition
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
How should meds be given through a tube
crush them and give them one at a time with flushing between pills -wait 30 min to return to
Reglin
increases GI motility and gets peristalsis happening
Important nursing considerations for PEG, G tubes, and J Tubes
skin care
teaching self care
body image and coping
tube dislodgement
referrals
What begins in the hospital prior to discharge
promoting home, community based, and transitional care
To move/discharge tube patients home, what should be done before
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
A nasally placed feeding tube should stay in place for no more than ____ weeks before being replaced with a new tube
4 weeks
When administering continuous or cyclic tube feedings, a primary nursing responsibility is preventing ___ pneumonia
aspiration
T/F: The most commonly used single lumen nasogastric tube is the gastric (Salem) pump
False
T/F: Visualizing the placement of a nasogastric or nasoenteric tube on X Ray (radiograph) is the only definitive way to verify its locations
True
T/F: When administering oral medications to a patient receiving tube feedings, medications may be crushed and mixed with the feeding formula
False
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
Check Tube Placement
Elevate HOB
Give Small Frequent Feedings
Avoid Over sedation of Patient
Check residual volume per policy
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
every 4 hours; install 30 mL of water with 50 mL or 60 mL syringe
