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NRSG 202 > Week 5 - Enteral Feeding/ Medication Admin through feeding tube > Flashcards

Week 5 - Enteral Feeding/ Medication Admin through feeding tube Flashcards

1
Q

What are the 9 regions of the abdomen?

A
  • right hypochondriac region
  • epigastric region
  • left hypochondriac region
  • right lumbar region
  • umbilical region
  • left lumbar region
  • right iliac region
  • hypogastric region
  • left iliac region
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2
Q

in regards to the 9 regions of the abdomen, what is included in the right hypochondriac region?

A
  • right lower lobe of liver
  • gallbladder
  • part of duodenum
  • hepatic flexure of colon
  • upper half of right kidney
  • suprarenal gland
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3
Q

in regards to the 9 regions of the abdomen, what is included in the epigastric region?

A
  • pyloric end of stomach
  • part of duodenum
  • head of pancreas
  • portion of liver
  • aorta
  • renal arteries
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4
Q

in regards to the 9 regions of the abdomen, what is included in the left hypochondriac region?

A
  • stomach
  • spleen
  • tail of pancreas
  • splenic flexure
  • upper portion of left kidney
  • suprarenal gland
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5
Q

in regards to the 9 regions of the abdomen, what is included in the right lumbar (flank) region?

A
  • lower half of right kidney
  • hepatic flexure of colon
  • ascending colon
  • part of duodenum
  • part of jejunum
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6
Q

in regards to the 9 regions of the abdomen, what is included in the umbilical region?

A
  • lower duodenum
  • jejunum
  • ileum
  • aorta
  • femoral arteries
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7
Q

in regards to the 9 regions of the abdomen, what is included in the left lumbar (flank) region?

A
  • descending colon
  • lower half of kidney
  • part of jejunum
  • part of ileum
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8
Q

in regards to the 9 regions of the abdomen, what is included in the right iliac (inguinal) region?

A
  • cecum
  • appendix
  • lower end of ileum
  • right femoral artery
  • right ureter
  • right spermatic cord
  • right overy
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9
Q

in regards to the 9 regions of the abdomen, what is included in the hypogastric (pubic) region?

A
  • ileum
  • bladder (if distended)
  • uterus (if enlarged)
  • aorta
  • femoral
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10
Q

in regards to the 9 regions of the abdomen, what is included in the left iliac (inguinal) region?

A
  • sigmoid colon
  • left ureter
  • left spermatic cord
  • left femoral artery
  • left ovary
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11
Q

What does chondriac mean?

A

cartilage

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12
Q

What other sounds can be heard when auscultating the abdomen?

A
  • bruits

- extra sounds don’t always indicate disease

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13
Q

What arteries can you listen to when auscultating the abdomen?

A
  • aorta
  • right/ left renal artery
  • right/ left iliac artery
  • right/ left femoral artery
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14
Q

New advanced GI/GU assessment skills will help you determine what?

A
  • what disease process could be occurring

- documenting findings from assessment

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15
Q

what is enteral nutrition?

A

administration of nutrients directly into the gastrointestinal tract

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16
Q

What is the preferred method for providing nutrition and should be used when patients GI tract is functional?

A

enteral nutrition

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17
Q

What is enteral nutrition considered? Why?

A
  • advanced directive

- may be ethical implications associated with intervention

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18
Q

describe malnutrition/ undernutrition

A
  • lack of necessary or appropriate food substances
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19
Q

what are signs and symptoms of malnutrition/ undernutrition?

A
  • mental confusion/ irritability
  • no appetite
  • changes in skin colour
  • dry/ scaly skin
  • sparse hair
  • swollen/ bleeding gums
  • dry eyes
  • fatigue
  • muscle weakness
  • distended abdomen
  • enlarged liver
  • weight loss
  • poor immune function
  • poor wound healing
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20
Q

What are abnormal blood results to watch for in regards to malnutrition ?

A
  • decreased albumin/pre-albumin
  • decreased hub/hct
  • decreased iron/components
  • decreased lymphocytes
  • decreased blood glucose
  • decreased K+ and calcium
  • decreased BUN and CR
  • increased liver enzymes
  • decreased serum vitamin and mineral levels
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21
Q

research over the past 30 years has shown that starvation/ parental nutrition fails to stimulate the gut resulting in what?

A
  • villous atrophy
  • loss of gut mass
  • compromising the physical barrier (decreased surface area)
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22
Q

What maintains gut mass, function and integrity?

A

enteral nutrition (oral + tube feeding)

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23
Q

early feeding is associated with what better outcomes?

A
  • decreased length of stay
  • decreased infection/ sepsis
  • increased nutrition goals
  • improved nitrogen balance
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24
Q

what is the difference between enteral and parenteral feeding?

A

enteral
- feeding via the stomach or intestine

parenteral
- feeding via an IV through a central vein

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25
Q

What type of feed would be fatal if given in blood?

A

enteral formula

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26
Q

what are the indications for an enteral feed?

A
  • need functioning GI tract
  • malnourished/ at risk of malnutrition
  • supplement food intake when insufficient
  • unable/ unwilling to inject oral foods
  • upper GI track impaired
  • dysphagia
  • critical illness
  • malabsorption disorders
  • decreased LOC/ coma
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27
Q

What are the indications for a parenteral feed?

A

non-functioning GI tract

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28
Q

A parenteral feed is administered through what?

A
  • central vascular access device (CVAD)

- PICC preferred route

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29
Q

What are contraindications for enteral feeding?

A
  • should have gag reflex
  • GI tract not functioning
  • must be able to elevate HOB during feeds
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30
Q

What are some complications of an enteral feed ?

A
  • referring syndrome
  • aspiration
  • metabolic problems
  • over-hydration
  • hypo/hypernatremia
  • tube dislodgement
  • infection
  • GI side effects
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31
Q

when does re-feeding syndrome occur?

A

in previously malnourished patients who are fed with high carbohydrate loads

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32
Q

in regards to re-feeding syndrome what can carbohydrates cause?

A
  • large increase in circulating insulin level

- results in rapid/ dramatic fall in phosphate, potassium, magnesium with increase extracellular fluid volume

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33
Q

in regards to re-feeding syndrome explain what could happen in the body when it switches from catabolic to using exogenous fuel sources

A
  • increase in O2 consumption
  • increased resp and cardiac workload
  • demand for nutrients/ oxygen may outstrip supply
  • both can lead to multiple organ failure, resp/ cardiac failure, seizures, leukocyte dysfunction
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34
Q

in regards to re-feeding syndrome explain what happens to the gut

A
  • may have undergone some atrophy with starvation

- return of enteral feed may be intolerance to feed with nausea/ diarrhea

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35
Q

in regards to re-feeding syndrome what should be done when clients are reintroduced to food?

A
  • feeds should started slowly

- electrolytes closely monitored/ adequately replaced to avoid problems developing

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36
Q

how do you prevent aspiration from occurring?

A

head of bed elevated while on continuous tube feed and for 1hr after intermittent feeds

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37
Q

What are signs to observe for in regards to aspiration?

A
  • increased SOB
  • productive cough
  • sputum (note color)
  • difficulty swallowing
  • assess gag reflex
  • temperature
  • HR
  • RR
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38
Q

What are the different types of nasal feeding tubes?

A
  • nasogastric tube
  • large bore NG tube
  • small bore NG tube
  • nato-enteric tube
  • naso-duodenal (NG)
  • nasa-jejunal (NJ)
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39
Q

describe nasogastric tubes

A
  • inserted into nostril down into stomach
  • requires intact gag/cough reflex
  • must have adequate gastric emptying
  • short term feeding (<4-6 weeks)
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40
Q

who can insert a nasogastric tube?

A

usually inserted by a nurse unless a contraindication

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41
Q

What are the 2 types of large bore NG tubes?

A
  • salem sump

- levin

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42
Q

in regards to large bore NG tubes describe salem sump

A
  • larger tube
  • double lumen
  • holes near the tip
  • usually 12-18FR diameter
  • need to be changed weekly
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43
Q

What can large bore NG Salem sumps also be used for?

A

suction as smaller vent lumen allows for inflow of air > prevents vacuum if tube adheres to stomach wall

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44
Q

in regards to large bore NG tubes describe levin

A
  • not as common
  • single lumen
  • often used with anti-reflux valve
  • need to be changed weekly
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45
Q

what are anti-reflux valves used with?

A

large bore NG tubes

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46
Q

what do anti-reflux valves prevent?

A

gastric reflux/ leakage through vent lumen of double lumen nasogastric tube

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47
Q

what does the valve in the anti-reflux valve allow?

A

passage of air into vent lumen when atmospheric pressure exceeds stomach pressure

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48
Q

what does the valve in the anti-reflux valve do when stomach pressure exceeds atmospheric pressure?

A

valve prevents flow of fluids through the tube

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49
Q

How does the anti-reflux valve attach?

A

by connecting the “blue end of the reflux valve to the blue vent opening”

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50
Q

describe small bore NG tubes

A
  • most common for general feeding
  • usually 6-12FR diameter
  • smaller/ flexible
  • less irritating
  • may have weighted tip
  • have stylet to assist insertion
  • need to be changed monthly
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51
Q

what are the 2 types of nasogastric-enteric tubes?

A
  • naso-duodenal

- nasa-jejunal

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52
Q

naso-enteri tubes are longer than what? how long should they be?

A
  • longer than a nasogastric tube (40cm+)
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53
Q

describe nato-enteric tubes

A
  • inserted into upper small intestine
  • usually greater dilution and smaller volumes
  • used for clients at risk of aspiration
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54
Q

for clients who are at risk of aspiration with a nasogastric- enteric tube what could be causing their aspiration?

A
  • decreased LOS
  • poor/absent cough/ gag reflex
  • endotracheal intubation
  • recent extubation
  • inability to cooperate c procedure
  • restlessness or agitation
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55
Q

What is used to secure nasal feeding tubes?

A
  • nasal tape

- nasal bridle

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56
Q

what are some complications of nasal tubes?

A
  • nasal pharyngeal irritation
  • misplacement of tube
  • perforation
  • inadvertent lung placement
  • aspiration
  • intracranial placement
  • sinusitis
  • sore throat
  • epistaxis
57
Q

describe a gastrostomy tube (G-tube) and jejunostomy (J-tube)

A
  • inserted through abdomen wall into stomach or jejunem
  • used for more than 6-8 weeks
  • placed surgically or by laparoscopy
  • larger abdominal incision
  • longer NPO time before starting feeds
58
Q

what does PEG stand for?

A

percutaneous endoscopic gastrostomy

59
Q

what does PEJ stand for?

A

percutaneous endoscopic jejunostomy

60
Q

describe PEG and PEJ tubes

A
  • used for more than 6-8 weeks
  • smaller abdominal incision
  • shorter NPO time (start feeds by 24hrs)
  • catheter c external bumper
  • internal inflatable retention balloon to maintain place
61
Q

how is a PEG or PEJ inserted?

A
  • endoscope to visualize inside of stomach
  • make puncture through skin
  • insert tube through puncture
62
Q

What are some complications of G/PEG and J/PEJ tubes?

A
  • peristomal infection
  • leakage
  • accidental tube removal
  • tube blockage
  • tube fracture
  • tube displacement
  • peritonitis
  • aspiration pneumonia
  • bleeding
63
Q

What are the aspiration risk factors for all feeding tubes?

A
  • head of bed <30 degrees
  • impaired LOS
  • neurological deficits
  • poor oral health
  • Mal-positioned feeding tube
  • +60yrs
  • delayed gastric emptying
  • gastroesophageal reflex
64
Q

What do you do for aspiration treatment?

A
  • stop feed
  • lower head of bed
  • put client on L side, prevent further seepage into lungs
  • suction if necessary
  • administer O2
  • notify MD
  • continue suctioning PRN
65
Q

when is a closed system/ continuous drip feeding system used?

A

used initially when client does not tolerate bolus

66
Q

whats the container size thats used for a closed system/ continuous drip feeding system?

A

1000-1500mL container

67
Q

whats the hang time for closed system/ continuous drip feeding system if sterile technique is used?

A

hang time 24-48hrs

68
Q

why would you administer a closed system/ continuous drip feeding at night?

A

so patient can attempt to eat during the day

69
Q

when are closed system/ continuous drip feeding essential?

A

when feedings are administered into small bowel

70
Q

when do you need to change the bag and tubing for a closed system/ continuous drip feeding?

A

q24-48hrs

71
Q

what is used to run a closed system/ continuous drip feed? and what rate is it started at?

A
  • pump is used

- started at a slow rate and increased as tolerated

72
Q

when is an open system/ bolus or intermittent feeding system used?

A

when client able to tolerate bolus feeds

73
Q

What can you put in an open system/ bolus or intermittent feeding system

A

250mL tetra packs or cans or dry podwer

74
Q

what amount is given in an open system/ bolus or intermittent feeding system?

A

300-500mL given several times /day

75
Q

over what time is an open system/ bolus or intermittent feeding done?

A

at least 30mins

76
Q

Where must an open system/ bolus or intermittent feeding be administered?

A

only in stomach

- monitor for aspiration/ distension

77
Q

How can an open system/ bolus or intermittent feeding be administered?

A
  • feeding pump
  • gravity drip
  • syringe (without plunger)
78
Q

How are the bag and tubing taken care of for an open system/ bolus or intermittent feeding system?

A
  • bags and tubing rinsed with tap water/ drained and hung to dry at the end of feeds
    ex. breakfast, lunch, dinner
79
Q

What do feeding system connectors improve?

A

patient safety by decreasing risk of medical device misconnections

80
Q

What do all feeding systems need to be labelled with?

A
  • client information
  • date/time
  • preparer’s initials
  • enteral feeding formula type, rate, strength, amount
81
Q

in regards to feeding systems what needs to be put on administration set?

A
  • “tubing feeding only”

- do not use marker to record info directly on feeding set

82
Q

where do you need to label the feeding system?

A

close to the client at the site close to the source when there are different access sites/ several bags

83
Q

What other supplies is needed for enteral feeding?

A
  • 60ml Cath-tip syringe
  • container for water
  • attachments (connectors, stopcocks, valves)
84
Q

a standard formula of enteral feeding provides what?

A
  • 1kcal/mL of solution

- contains protein, fat, carbohydrate, minerals, vitamins

85
Q

what are available formulas for enteral feeding?

A
  • low volume
  • high fibre
  • high protein
  • low sugar/ CHO
  • high nitrogen
  • with fibre for treatment of diarrhea
  • pre-digested/ easy to absorb
  • natural formula
86
Q

what are the hang times for enteral formulas?

A 
- 8hrs
tetra pack (ready to use formula)
  • 4hrs
    reconstituted powder formula
  • 48hrs
    closed system formula bottles
87
Q

when do open feeding systems need to be changed?

A

every 24hrs

88
Q

when do closed feeding systems need to be changed?

A

every 48hrs or when bag empties which ever comes first

89
Q

When does accessory equipment for feeding systems need to be changed?

A

q24hrs

syringes, bowls, cups

90
Q

when do attachments need to be changed for feeding systems?

A

weekly

stopcocks, valves

91
Q

what do you need prior to initiating a feeding ?

A
  • doctors order for enteral feeds

- xray confirming placement prior to starting

92
Q

What kinds of feedings tubes do not require X-ray confirmation of placement?

A

surgically or radiologically placed feeding tubes

93
Q

who should be consulted for all clients with enteral feeding?

A

registered dietician

94
Q

What does a registered dietitian determine?

A
  • total free water requirement
  • total caloric requirement
  • normal saline may be ordered if sodium low
95
Q

describe total free water requirement

A
  • amount of fluid client needs in 24hr period to sustain life
  • enteral formula contains 60-85% free water
96
Q

if a client is NOT at high risk for referring syndrome what will there rate be at?

A
  • full strength
  • 25mL/hr X8hrs (can then increase if tolerated)
  • increase to 50mL/hr and then by 25mL Q8H to goal rate
97
Q

if a client is at high risk for referring syndrome what will there rate be at?

A
  • full strength starting at 25mL/hr X 24hrs

- if tolerated of 8hrs increase to 40mL/hr

98
Q

after you crush meds what do you need to put on a plastic med cup?

A
  • label with patient name/ birthdate
  • drug name
  • dose
  • route
99
Q

when do you need to flush a feeding tube?

A
  • q4hrs for continuous feeds
  • flush pre/post med admin
  • flush pre/post intermittent/ bolus feeds
  • flush q4hrs if feeding tube not in use
100
Q

What is used for flushing a feeding tube?

A
  • filtered tap water
  • sterile water if immunocompromised or infant <1yr
  • saline solution if patient has low sodium
101
Q

what are some reasons for a tube occlusion ?

A
  • inadequate flushing
  • tube resting on mucous wall
  • coagulation of enteral feeding formula
  • certain meds
  • combining meds
  • not crushing meds
  • using a small bore feeding tube
102
Q

how do you prevent feeding tube occlusions

A

flush with min 30mL water q4h when feeds are stopped

103
Q

What is included in the nursing care prior to starting tube feed? i.e what do you need to do first?

A
  • check orders/ MAR for the of feeding tube, solution
  • check for x-ray report
  • initial feed > determine if client at risk for refeeding syndrome
  • review gastric residual orders
  • ensure nutritional assessment done
  • check last weight recorded
  • review recent lab results
  • gather supplies
  • complete baseline assessment
104
Q

what is the most accurate way to confirm a placement of an NG tube that is used for feeding purposes?

A

x-ray

105
Q

what should be included in the baseline assessment for nursing care prior to starting tube feed?

A
  • Resp and CNS assessment
  • GI assessment initially then q4hrs and pen or prior to each bolus feed
  • hydration assessment
  • weight if needed (2x/week)
  • assess tube site and feeding solution
106
Q

how are you going to assess feeding tube placement?

A
  1. NG external length measurement - nare to end of tube
  2. aspirate for stomach contents
  3. measure the pH
  4. auscultating over the stomach (not reliable rarely used)
107
Q

what needs to be done before each feed every shift?

A

NG tube placement needs to be assessed and measurement recorded

108
Q

in regards to how you’re going to assess feeding tube placement describe NG external length measurement - nare to end of tube

A
  • use long measuring tape

- should be recorded on chart

109
Q

in regards to how you’re going to assess feeding tube placement describe aspirating for stomach contents

A
  • exception small bore NG tubes
  • inject 30mL of air into the tube
  • aspirate 5-10mL GI contents with a syringe
  • verify residuals are gastric contents (stomach > bile, straw coloured, intestinal contents > amber or brown)
110
Q

in regards to how you’re going to assess feeding tube placement describe measure the pH

A
  • gastric pH 1-4 but could be as high as 6
  • intestinal ph 6+
  • respiratory usually 7+ but can be as low as 6
  • not done by nurses on ward
111
Q

in regards to how you’re going to assess feeding tube placement describe auscultating over the stomach

A
  • listen for a “whooshing” or “gurgling” sound the air is inserted
112
Q

When should you NOT check a gastric residuals ?

A
  • for small bore NG tubes

- on tubes past the stomach

113
Q

What do you used to check a gastric residual?

A
  • 60mL syringe

- extra bowl if withdrawing more than syringe

114
Q

How do you check gastric residuals?

A
  • put 10-20mL of air into tube to release from stomach wall
  • aspirate all fluid in stomach/ mesure
  • flush tube with 10-30mL of water following residual checks
115
Q

What are you going to monitor during an enteral feed?

A
  • ensure Hob elevated 30-45 degrees

monitor

  • breathing especially those at risk for aspiration
  • discomfort/ tolerance
116
Q

What do you need to do following a bolus enteral feed?

A
  • teach client to sit upright for 1hr after
  • GI assessment
  • evaluate effects/ tolerance of feeding
  • mouth care q4hrs/ prn
  • nasal site care prn
  • PEG/PEJ site care
  • observe for nutritional improvement
  • documentation
117
Q

what do you need to do in regards to performing PEG/PEJ site care?

A
  • cleanse site daily with mild soap/water, pat dry
  • daily rotation of skin disc or cross bar to prevent skin breakdown
  • daily rotation of gastronomy tube > release sticking
  • dressing if needed
  • take C&S swab if S&S if infection
118
Q

What is included in assessing and monitoring for tolerance/ intolerance?

A
  • confirmation of placement
  • client tolerance of feeds
  • assess for intolerance
  • gastric tube residuals
  • dumping syndrome
  • referring syndrome
  • monitor weight
119
Q

what are some skin problems associated with PEG/ PEJ and G/J tube sites

A
  • skin irritation from tube/ allergy
  • mechanical trauma
  • chemical dermatitis
  • infection
  • granulation tissue formation
120
Q

What kind of infections can be seen in skin problems associated with PEG/ PEJ and G/J tube sites?

A
  • folliculitis
  • candidiasis
  • cellulitis
121
Q

What are the 8 steps to setting up an intermittent enteral feeding?

A
  1. check orders/ MAR
  2. wash hands
  3. gather supplies
  4. pour formula into bag
  5. prime tube feed bag/ tubing by opening clamp
  6. program pump
  7. after assessment flush tube with water
  8. connect tubing to feeding tube/ start
122
Q

in regards to the 8 steps to setting up an intermittent enteral feeding describe gather supplies

A
  • intermittent feeding bag/ tubing set
  • enteral formula
  • clean gloves
  • feeding pump
123
Q

increased residuals may indicate what?

A

delayed gastric emptying

124
Q

When checking residuals on tubes in the stomach what are you determining?

A

gastric emptying

125
Q

How often are you supposed to check gastric tubes?

A

q4hrs for first 48hrs of feeding and prn if warranted

126
Q

Do you continue to check gastric tubes if the client is unconscious ?

A

yes, check q4hrs and record residuals

127
Q

See physician orders or PPO to specify what in regards to gastric residuals?

A

how much residual should be present before holding feeds

128
Q

What can holding or stopping feeds lead to?

A

client receiving insufficient calories/ protein

129
Q

When do you not stop tube feeds?

A
  • routine nursing care
  • client positioning when HOB temporarily lowered
  • during bedside procedure unless specifically ordered by physician
130
Q

If feed is interrupted (test, surgery) what rate should the feed be at once started again?

A

same rate prior unless ordered otherwise

131
Q

When should you consider holding feeds?

A

prior to supine physiotherapy

132
Q

Do not stop feeds or decrease rate for what?

A
  • single elevated GRV
  • absent BS
  • diarrhea
  • emesis related to suctioning
133
Q

contact registered dietician to recalculate rates if feeds are what?

A

regularly held for

  • procedures
  • physio
  • meds
  • oral intake initiated
134
Q

when should detailed abdominal assessments be done?

A
  • q4h continuous feed

- before each feed if bolus feed

135
Q

How often should clients be weighed?

A

2x/week

136
Q

how often does a confirmation of tube placement including gastric aspirate need to be done?

A

q24hr and documented on 24r flow sheet

137
Q

What do you need to document in the 24hr flow sheet in regards to feeding tubes?

A
  • gastric residual aspirate/ amount
  • interventions
  • condition/ care of skin at tube site
  • size, type, external length of feeding tube for NG
  • post-feed assessment/ tolerance
138
Q

What do you need to document in the MAR/in/out record in regards to feeding tubes?

A
  • enteral feeding solution, type, rate, amount given, continuous/ intermittent
  • total amount of water flushes
  • medication administration

NRSG 202 (11 decks)

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