Week 5: Enteral Feeding Flashcards
What are abdominal bruits
Additionally sounds sometimes heard during auscultation (swishing sound) that can indicate aortic aneurysm, but does not ALWAYS indicate disease
What is enteral nutrition?
Administration of nutrients directly into the GI tract
What is the preferred method for providing nutrition
enteral nutrition
what MUST the patient have in order to have enteral nutrition
a functioning GI tract
What is enteral nutrition considered?
An advanced directive that may have ethical implications associated with this intervention
What is malnutrition
the lack of necessary or appropriate food substances
S&S of Malnutrition
mental confusion, irritability
inability to concentrate
lack of appetite or interest in food
changes in skin colour
dry scaly skin
brittle pale nails
dully sparse hair
swollen and bleeding gums, decaying teeth
sunken dry eyes
hollow cheeks
fatigue low energy
muscle wasting
distended abdomen
enlarged liver
weight loss muscle wasting
poor immune function
Abnormal blood results in malnutrition
DECREASED:
- albumin
- Hgb
- iron
- lymphocytes
- blood glucose
- K+ and calcium
- BUN and CR
- serum vitamins and mineral levels
INCREASED:
- liver enzymes
What happens when patients are starved
villous atrophy
loss of gut mass
compromising the physical barrier (decreased surface area)
Enteral nutrion
maintains fut mass, function, and integrity
Early feeding provides these outcomes
decreased length of stay
decreased infection/sepsis
increased nutritional goal
improved nitrogen balance
Parenteral feeding
via an IV through a central vein
Indications for an Enteral feeding
functioning and accessible GI tract
malnourished or at risk of malnutrition
to supplement food intake
unable to ingest oral food
unwilling to take oral feeds
upper GI tract impairment
Dysphagia
critical illness
malabsorption disorders
decreased LOC, coma
Parenteral feed is used when the patient
has a NON FUNCTIONING GI tract
Contraindications for enteral feeding
- no gag reflex
- non functioning GI tract
- cannot elevate HOB
Complications of enteral feeding
referring syndrome
aspiration
metabolic provlems
over hydration
hypo/hypernatremia
tube dislodgement
infection
GI side effects
How to prevent aspiration
ensure head of bead is elevated during feeding and for 1 hour following intermittent feeds
what S&S should be observed for with aspiration
increased SOB, productive cough, sputum, difficulty swallowing
assess gag reflex, temperature, HR, RR
What is a Nasogastric tube?
Inserted into nostril down into the stomach (nasal tubes are usually inserted by a nurse unless a contraindication)
What must a patient have in order to have a NG tube
intact gag/cough reflex and adequate gastric emptying
What is NG tubes required for
short term feedings (less than 4-6 weeks)
What is a Salem sump
A large bore NG tube that has a double lumen
What is a salem sumps usual size
12-18 FR
What may a salem sump also be used for?
Suction as the smaller vent lumen allows for an inflow of air which prevents vacuum if the tube adheres to the stomach wall
Levin
A large bore NG tube that has a single lumen, often used with an anti-reflux valve
How often does a levin tube need to be changed?
Weekly
Anti-reflux valve
Prevents gastric reflux or leakage through the vent lumen of a double lumen NG tube
What does the valve do on an anti-reflux valve
allows the passage of air into the vent lumen when atmospheric pressure exceeds stomach pressure
when stomach pressure exceeds atmospheric pressure the valve prevents the flow of fluids through the tube
What is a small bore NG tube?
Levin
most common in IH for enteral feeding
what is the diameter for a levin?
6-12 FR
What does a small NG tube look like
smaller more flexible less irritating
may have weighted tip
have stylet to assist insertion
How often does a small NG tube need to be changed?
Monthly
What is a Naso-enteric tube
longer than a nasogastric tube (40cm or grater)
inserted into the upper small intestine
usually greater dilution and smaller volumes
What is a Naso-enteric tube used for?
clients at risk of aspiration
What kinds of clients are at risk of aspiration
decreased LOC
poor or absent cough or gag reflexes
endotracheal intubation
recent extubation
inability to cooperate with procedure
restlessness or agitation
What are some complications of Nasal Tubes?
Nasal pharyngeal irritation and pain
misplacement of tube
perforations (lung, esophagus, stomach, small intestine)
Inadvertent lung placement
sinitus, sore throat, epistaxis
What is a gastrostomy tube (jejunostomy tube)
inserted THROUGH abdominal wall into the stomach or jejunum (placed laparoscopy)
larger abdominal incision
usually longer NPO time before starting feeds
How long is a gastronomy tube usually in for?
more than 6-8 weeks
What is a Percutaneous Endoscopic Gastrostomy (PEG)/Jejunostomy tube?
Uses an endoscope to visualize the inside of the stomach, making a puncture through the skin and inserting the tube through the puncture
smaller incision
shorter NPO time
catheter with external bumper
internal inflatable retention balloon to maintain placement
What are the indications for a long term feeding tube
Both inability to meet nutritional needs orally
death is not imminent
meets one:
has been more than 4-6 weeks on NG and/or orogastric feeds
Low probability of nutritional needs being met orally over the next 4-6 weeks
NG tube placement contraindicated
How long is a PEG tube in for
longer than 6-8 weeks
What are some complications of a PEG tube
Peristomal infection
leakage
accidental tube removal
tube blockage
tube fracture
tube displacement
peritonitis
aspiration pneumonia
bleeding
When do nurses check the feeding tubes balloons?
NOT for the first 4 weeks after insertion, after 4 weeks check volume weekly or per facility
What is the procedure for checking a tube feeds balloon?
Verify initial volume on insertion
use a slip tip syringe to avoid damage
remove all old wattle from balloon, measure and discard
with new syringe, draw up right amount and reinflate balloon
What are aspiration risk factors for all feeding tubes?
HOB less than 30 degrees
impaired LOC
neuro deficits
poor oral health
Mal-positioned feeding tube
gastroesophageal reflex
age over 60 years
delayed gastric emptying
What is aspiration treatment?
STOP FEEDS
Lowe HOB and put pt on left side (to prevent further seepage of formula into lungs)
suction PRN
administer O2 as needed
notify MD immediately
continue suctioning PRN
Whe is a closed system/continous drip used?
initially when the pt does not tolerate bolus
What is a closed system containers volume
1000-1500mL
How long can a closed system be hung?
up to 48 hours
when are closed systems essential
when feedings are administered into the small bowel
How often does a closed system tubing/bag need to be changed
up to Q48H
When is an open system/bolus or intermittent used
when the pt is able to tolerate bolus feeds
What are the typical sizes of open system
250mL tetra packs
usually 300-500mL given several times per day
How long is open system usually administered
at least over 30 minutes
Where must open system feeds be administered
given only in the stomach (monitor for aspiration and distension)
How to treat for open system feeding
rinsed with tap water, drained, and hung to dry following intermittent feeds
All feeding systems need to be labelled with
Pt information
date/time
preparer’s initials
enteral feeding formula type, rate, strength, and amount
Enteral feeding formulas
provides 1kcal/mL of solution with protein, fat, carbs, minerals, and vitamins in specific proportions
What are available enteral feeding formulas
Low volume
high fibre
high protein
low sugar/CHO
high nitrogen
with finer for diarrhea tot
pre-digested and easy to absorb
natural formula
how long can a tetra pack be hung
8 hrs
How long can a reconstituted powder formula be hung
4 hours
how long can a closed system formula bottle be hung
48 hrs
How often does a normal system need to be changed
Q24hrs
How often does a closed system need to be changed?
Q48hrs
how often does feeding accessory equipment need to be changed?
Q24hrs
How often does feeding attachments need to be changed?
weekly
What is needed prior to initiating a feed?
- doctors order
- X ray confirming tube placement
- documentation of confirmation of tube placement
- dietician consulted for all enteral feed pts
what is a total free water requirement
amount of fluid client needs in a 24 hours period to sustain life
how much free water do enteral formulas contain?
60-85% free water
what may be ordered if sodium is low
NS
What are the feeding rates if the pt is not at high risk for referring syndrome?
full strength starting at 25mL/hr x8 hrs then increased if tolerated
increase to 50mL/hr then by 25mL Q8H to goal rate
What are the feeding rates for a patient at high risk for referring syndrome?
full strength starting at 25mL/hr for 24hrs if tolerated for 8hrs increase to 40mL/hr
what needs to happen pre and post med admin
flush with tap water
when crushing medication how much water does it need to be dissolved in?
30mL
how much water should be added to thick medications
5-10mL to prevent blockage
what occurs at the bedside when giving meds through tube
perform abdominal assessment
assess tube site and tube placement
stop feed
assess content and residuals if needed
flush tube at least 30mL water before, between and after
restart feed is required
document
How much water if normal fluid allowed
30 mL before 30 with med 30 after
how much fluid if restricted
15 before med 30 with med 15 after
how often does a continous tube feed need to be flushed
Q4H
What are some reasons for a tube occlusion
inadequate flushing
tube resting on mucosa wall
coagulation of enteral feeding formula
certain medications, combining meds, and/or not crushing meds fine enough
using too small of a bore tube
What assessments need to be done prior to enteral feed
baseline resp assessment
baseline CNS assessment
GI assessment
hydration assessment
weight
tube site assessment
feeding solution, expirary date, rate of admin
What are the 4 things to assess with feeding tube placement?
- External length measurement - are to end of tube
- aspirate for stomach content
- measure the pH
- Auscultating over the stomach
Gastric Residuals
use 60mL syringe
put 10-20mL of air into tube
flush with 10-30ml water after
