Week 5 - Enteral Feeding/ Medication Admin through feeding tube Flashcards
What are the 9 regions of the abdomen?
- right hypochondriac region
- epigastric region
- left hypochondriac region
- right lumbar region
- umbilical region
- left lumbar region
- right iliac region
- hypogastric region
- left iliac region
in regards to the 9 regions of the abdomen, what is included in the right hypochondriac region?
- right lower lobe of liver
- gallbladder
- part of duodenum
- hepatic flexure of colon
- upper half of right kidney
- suprarenal gland
in regards to the 9 regions of the abdomen, what is included in the epigastric region?
- pyloric end of stomach
- part of duodenum
- head of pancreas
- portion of liver
- aorta
- renal arteries
in regards to the 9 regions of the abdomen, what is included in the left hypochondriac region?
- stomach
- spleen
- tail of pancreas
- splenic flexure
- upper portion of left kidney
- suprarenal gland
in regards to the 9 regions of the abdomen, what is included in the right lumbar (flank) region?
- lower half of right kidney
- hepatic flexure of colon
- ascending colon
- part of duodenum
- part of jejunum
in regards to the 9 regions of the abdomen, what is included in the umbilical region?
- lower duodenum
- jejunum
- ileum
- aorta
- femoral arteries
in regards to the 9 regions of the abdomen, what is included in the left lumbar (flank) region?
- descending colon
- lower half of kidney
- part of jejunum
- part of ileum
in regards to the 9 regions of the abdomen, what is included in the right iliac (inguinal) region?
- cecum
- appendix
- lower end of ileum
- right femoral artery
- right ureter
- right spermatic cord
- right overy
in regards to the 9 regions of the abdomen, what is included in the hypogastric (pubic) region?
- ileum
- bladder (if distended)
- uterus (if enlarged)
- aorta
- femoral
in regards to the 9 regions of the abdomen, what is included in the left iliac (inguinal) region?
- sigmoid colon
- left ureter
- left spermatic cord
- left femoral artery
- left ovary
What does chondriac mean?
cartilage
What other sounds can be heard when auscultating the abdomen?
- bruits
- extra sounds don’t always indicate disease
What arteries can you listen to when auscultating the abdomen?
- aorta
- right/ left renal artery
- right/ left iliac artery
- right/ left femoral artery
New advanced GI/GU assessment skills will help you determine what?
- what disease process could be occurring
- documenting findings from assessment
what is enteral nutrition?
administration of nutrients directly into the gastrointestinal tract
What is the preferred method for providing nutrition and should be used when patients GI tract is functional?
enteral nutrition
What is enteral nutrition considered? Why?
- advanced directive
- may be ethical implications associated with intervention
describe malnutrition/ undernutrition
- lack of necessary or appropriate food substances
what are signs and symptoms of malnutrition/ undernutrition?
- 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
What are abnormal blood results to watch for in regards to malnutrition ?
- 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
research over the past 30 years has shown that starvation/ parental nutrition fails to stimulate the gut resulting in what?
- villous atrophy
- loss of gut mass
- compromising the physical barrier (decreased surface area)
What maintains gut mass, function and integrity?
enteral nutrition (oral + tube feeding)
early feeding is associated with what better outcomes?
- decreased length of stay
- decreased infection/ sepsis
- increased nutrition goals
- improved nitrogen balance
what is the difference between enteral and parenteral feeding?
enteral
- feeding via the stomach or intestine
parenteral
- feeding via an IV through a central vein
What type of feed would be fatal if given in blood?
enteral formula
what are the indications for an enteral feed?
- 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
What are the indications for a parenteral feed?
non-functioning GI tract
A parenteral feed is administered through what?
- central vascular access device (CVAD)
- PICC preferred route
What are contraindications for enteral feeding?
- should have gag reflex
- GI tract not functioning
- must be able to elevate HOB during feeds
What are some complications of an enteral feed ?
- referring syndrome
- aspiration
- metabolic problems
- over-hydration
- hypo/hypernatremia
- tube dislodgement
- infection
- GI side effects
when does re-feeding syndrome occur?
in previously malnourished patients who are fed with high carbohydrate loads
in regards to re-feeding syndrome what can carbohydrates cause?
- large increase in circulating insulin level
- results in rapid/ dramatic fall in phosphate, potassium, magnesium with increase extracellular fluid volume
in regards to re-feeding syndrome explain what could happen in the body when it switches from catabolic to using exogenous fuel sources
- 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
in regards to re-feeding syndrome explain what happens to the gut
- may have undergone some atrophy with starvation
- return of enteral feed may be intolerance to feed with nausea/ diarrhea
in regards to re-feeding syndrome what should be done when clients are reintroduced to food?
- feeds should started slowly
- electrolytes closely monitored/ adequately replaced to avoid problems developing
how do you prevent aspiration from occurring?
head of bed elevated while on continuous tube feed and for 1hr after intermittent feeds
What are signs to observe for in regards to aspiration?
- increased SOB
- productive cough
- sputum (note color)
- difficulty swallowing
- assess gag reflex
- temperature
- HR
- RR
What are the different types of nasal feeding tubes?
- nasogastric tube
- large bore NG tube
- small bore NG tube
- nato-enteric tube
- naso-duodenal (NG)
- nasa-jejunal (NJ)
describe nasogastric tubes
- inserted into nostril down into stomach
- requires intact gag/cough reflex
- must have adequate gastric emptying
- short term feeding (<4-6 weeks)
who can insert a nasogastric tube?
usually inserted by a nurse unless a contraindication
What are the 2 types of large bore NG tubes?
- salem sump
- levin
in regards to large bore NG tubes describe salem sump
- larger tube
- double lumen
- holes near the tip
- usually 12-18FR diameter
- need to be changed weekly
What can large bore NG Salem sumps also be used for?
suction as smaller vent lumen allows for inflow of air > prevents vacuum if tube adheres to stomach wall
in regards to large bore NG tubes describe levin
- not as common
- single lumen
- often used with anti-reflux valve
- need to be changed weekly
what are anti-reflux valves used with?
large bore NG tubes
what do anti-reflux valves prevent?
gastric reflux/ leakage through vent lumen of double lumen nasogastric tube
what does the valve in the anti-reflux valve allow?
passage of air into vent lumen when atmospheric pressure exceeds stomach pressure
what does the valve in the anti-reflux valve do when stomach pressure exceeds atmospheric pressure?
valve prevents flow of fluids through the tube
How does the anti-reflux valve attach?
by connecting the “blue end of the reflux valve to the blue vent opening”
describe small bore NG tubes
- 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
what are the 2 types of nasogastric-enteric tubes?
- naso-duodenal
- nasa-jejunal
naso-enteri tubes are longer than what? how long should they be?
- longer than a nasogastric tube (40cm+)
describe nato-enteric tubes
- inserted into upper small intestine
- usually greater dilution and smaller volumes
- used for clients at risk of aspiration
for clients who are at risk of aspiration with a nasogastric- enteric tube what could be causing their aspiration?
- decreased LOS
- poor/absent cough/ gag reflex
- endotracheal intubation
- recent extubation
- inability to cooperate c procedure
- restlessness or agitation
What is used to secure nasal feeding tubes?
- nasal tape
- nasal bridle
what are some complications of nasal tubes?
- nasal pharyngeal irritation
- misplacement of tube
- perforation
- inadvertent lung placement
- aspiration
- intracranial placement
- sinusitis
- sore throat
- epistaxis
describe a gastrostomy tube (G-tube) and jejunostomy (J-tube)
- 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
what does PEG stand for?
percutaneous endoscopic gastrostomy
what does PEJ stand for?
percutaneous endoscopic jejunostomy
describe PEG and PEJ tubes
- 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
how is a PEG or PEJ inserted?
- endoscope to visualize inside of stomach
- make puncture through skin
- insert tube through puncture
What are some complications of G/PEG and J/PEJ tubes?
- peristomal infection
- leakage
- accidental tube removal
- tube blockage
- tube fracture
- tube displacement
- peritonitis
- aspiration pneumonia
- bleeding
What are the aspiration risk factors for all feeding tubes?
- head of bed <30 degrees
- impaired LOS
- neurological deficits
- poor oral health
- Mal-positioned feeding tube
- +60yrs
- delayed gastric emptying
- gastroesophageal reflex
What do you do for aspiration treatment?
- 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
when is a closed system/ continuous drip feeding system used?
used initially when client does not tolerate bolus
whats the container size thats used for a closed system/ continuous drip feeding system?
1000-1500mL container
whats the hang time for closed system/ continuous drip feeding system if sterile technique is used?
hang time 24-48hrs
why would you administer a closed system/ continuous drip feeding at night?
so patient can attempt to eat during the day
when are closed system/ continuous drip feeding essential?
when feedings are administered into small bowel
when do you need to change the bag and tubing for a closed system/ continuous drip feeding?
q24-48hrs
what is used to run a closed system/ continuous drip feed? and what rate is it started at?
- pump is used
- started at a slow rate and increased as tolerated
when is an open system/ bolus or intermittent feeding system used?
when client able to tolerate bolus feeds
What can you put in an open system/ bolus or intermittent feeding system
250mL tetra packs or cans or dry podwer
what amount is given in an open system/ bolus or intermittent feeding system?
300-500mL given several times /day
over what time is an open system/ bolus or intermittent feeding done?
at least 30mins
Where must an open system/ bolus or intermittent feeding be administered?
only in stomach
- monitor for aspiration/ distension
How can an open system/ bolus or intermittent feeding be administered?
- feeding pump
- gravity drip
- syringe (without plunger)
How are the bag and tubing taken care of for an open system/ bolus or intermittent feeding system?
- bags and tubing rinsed with tap water/ drained and hung to dry at the end of feeds
ex. breakfast, lunch, dinner
What do feeding system connectors improve?
patient safety by decreasing risk of medical device misconnections
What do all feeding systems need to be labelled with?
- client information
- date/time
- preparer’s initials
- enteral feeding formula type, rate, strength, amount
in regards to feeding systems what needs to be put on administration set?
- “tubing feeding only”
- do not use marker to record info directly on feeding set
where do you need to label the feeding system?
close to the client at the site close to the source when there are different access sites/ several bags
What other supplies is needed for enteral feeding?
- 60ml Cath-tip syringe
- container for water
- attachments (connectors, stopcocks, valves)
a standard formula of enteral feeding provides what?
- 1kcal/mL of solution
- contains protein, fat, carbohydrate, minerals, vitamins
what are available formulas for enteral feeding?
- low volume
- high fibre
- high protein
- low sugar/ CHO
- high nitrogen
- with fibre for treatment of diarrhea
- pre-digested/ easy to absorb
- natural formula
what are the hang times for enteral formulas?
- 8hrs tetra pack (ready to use formula)
- 4hrs
reconstituted powder formula - 48hrs
closed system formula bottles
when do open feeding systems need to be changed?
every 24hrs
when do closed feeding systems need to be changed?
every 48hrs or when bag empties which ever comes first
When does accessory equipment for feeding systems need to be changed?
q24hrs
syringes, bowls, cups
when do attachments need to be changed for feeding systems?
weekly
stopcocks, valves
what do you need prior to initiating a feeding ?
- doctors order for enteral feeds
- xray confirming placement prior to starting
What kinds of feedings tubes do not require X-ray confirmation of placement?
surgically or radiologically placed feeding tubes
who should be consulted for all clients with enteral feeding?
registered dietician
What does a registered dietitian determine?
- total free water requirement
- total caloric requirement
- normal saline may be ordered if sodium low
describe total free water requirement
- amount of fluid client needs in 24hr period to sustain life
- enteral formula contains 60-85% free water
if a client is NOT at high risk for referring syndrome what will there rate be at?
- full strength
- 25mL/hr X8hrs (can then increase if tolerated)
- increase to 50mL/hr and then by 25mL Q8H to goal rate
if a client is at high risk for referring syndrome what will there rate be at?
- full strength starting at 25mL/hr X 24hrs
- if tolerated of 8hrs increase to 40mL/hr
after you crush meds what do you need to put on a plastic med cup?
- label with patient name/ birthdate
- drug name
- dose
- route
when do you need to flush a feeding tube?
- q4hrs for continuous feeds
- flush pre/post med admin
- flush pre/post intermittent/ bolus feeds
- flush q4hrs if feeding tube not in use
What is used for flushing a feeding tube?
- filtered tap water
- sterile water if immunocompromised or infant <1yr
- saline solution if patient has low sodium
what are some reasons for a tube occlusion ?
- 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
how do you prevent feeding tube occlusions
flush with min 30mL water q4h when feeds are stopped
What is included in the nursing care prior to starting tube feed? i.e what do you need to do first?
- 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
what is the most accurate way to confirm a placement of an NG tube that is used for feeding purposes?
x-ray
what should be included in the baseline assessment for nursing care prior to starting tube feed?
- 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
how are you going to assess feeding tube placement?
- NG external length measurement - nare to end of tube
- aspirate for stomach contents
- measure the pH
- auscultating over the stomach (not reliable rarely used)
what needs to be done before each feed every shift?
NG tube placement needs to be assessed and measurement recorded
in regards to how you’re going to assess feeding tube placement describe NG external length measurement - nare to end of tube
- use long measuring tape
- should be recorded on chart
in regards to how you’re going to assess feeding tube placement describe aspirating for stomach contents
- 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)
in regards to how you’re going to assess feeding tube placement describe measure the pH
- 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
in regards to how you’re going to assess feeding tube placement describe auscultating over the stomach
- listen for a “whooshing” or “gurgling” sound the air is inserted
When should you NOT check a gastric residuals ?
- for small bore NG tubes
- on tubes past the stomach
What do you used to check a gastric residual?
- 60mL syringe
- extra bowl if withdrawing more than syringe
How do you check gastric residuals?
- 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
What are you going to monitor during an enteral feed?
- ensure Hob elevated 30-45 degrees
monitor
- breathing especially those at risk for aspiration
- discomfort/ tolerance
What do you need to do following a bolus enteral feed?
- 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
what do you need to do in regards to performing PEG/PEJ site care?
- 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
What is included in assessing and monitoring for tolerance/ intolerance?
- confirmation of placement
- client tolerance of feeds
- assess for intolerance
- gastric tube residuals
- dumping syndrome
- referring syndrome
- monitor weight
what are some skin problems associated with PEG/ PEJ and G/J tube sites
- skin irritation from tube/ allergy
- mechanical trauma
- chemical dermatitis
- infection
- granulation tissue formation
What kind of infections can be seen in skin problems associated with PEG/ PEJ and G/J tube sites?
- folliculitis
- candidiasis
- cellulitis
What are the 8 steps to setting up an intermittent enteral feeding?
- check orders/ MAR
- wash hands
- gather supplies
- pour formula into bag
- prime tube feed bag/ tubing by opening clamp
- program pump
- after assessment flush tube with water
- connect tubing to feeding tube/ start
in regards to the 8 steps to setting up an intermittent enteral feeding describe gather supplies
- intermittent feeding bag/ tubing set
- enteral formula
- clean gloves
- feeding pump
increased residuals may indicate what?
delayed gastric emptying
When checking residuals on tubes in the stomach what are you determining?
gastric emptying
How often are you supposed to check gastric tubes?
q4hrs for first 48hrs of feeding and prn if warranted
Do you continue to check gastric tubes if the client is unconscious ?
yes, check q4hrs and record residuals
See physician orders or PPO to specify what in regards to gastric residuals?
how much residual should be present before holding feeds
What can holding or stopping feeds lead to?
client receiving insufficient calories/ protein
When do you not stop tube feeds?
- routine nursing care
- client positioning when HOB temporarily lowered
- during bedside procedure unless specifically ordered by physician
If feed is interrupted (test, surgery) what rate should the feed be at once started again?
same rate prior unless ordered otherwise
When should you consider holding feeds?
prior to supine physiotherapy
Do not stop feeds or decrease rate for what?
- single elevated GRV
- absent BS
- diarrhea
- emesis related to suctioning
contact registered dietician to recalculate rates if feeds are what?
regularly held for
- procedures
- physio
- meds
- oral intake initiated
when should detailed abdominal assessments be done?
- q4h continuous feed
- before each feed if bolus feed
How often should clients be weighed?
2x/week
how often does a confirmation of tube placement including gastric aspirate need to be done?
q24hr and documented on 24r flow sheet
What do you need to document in the 24hr flow sheet in regards to feeding tubes?
- 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
What do you need to document in the MAR/in/out record in regards to feeding tubes?
- enteral feeding solution, type, rate, amount given, continuous/ intermittent
- total amount of water flushes
- medication administration
