Week 7: Enteral/Parenteral Flashcards
Enteral
Nutrition delivered through the GI system (mouth, gastric tube)
Pt nutrition
NPO (nothing by mouth): to rest the GI tract; pre-op, severe V/D, bowel obstruction, dysphagia
Clear liquid: to slowly introduce nutrients to GI tract (tea, jelly, broth, ginger ale); post-op
Full liquid: (1) clear liquid and (2) foods that become liquid at room temp. (ice cream, sherbet)
Soft diet: pureed diet for poor dentition or dysphagia
As tolerated: go by what pt feels is tolerable
Restrictive diets:
- Cardiac (low sodium/fat)
- Diabetic (low sugar)
- Renal (low protein/sodium/K+, fluid restriction)
- Obese (calorie-restrictive)
Fluid restrictive diets
Visual fluid volume guides: indicate how many ml are in different items for I&O documentation
NG intubation
Purposes:
1. Gastric decompression: fluid or air is suctioned from the stomach (rest GI after bowel surgery, paralytic ileus)
- Gastric lavage: irrigation of the stomach to remove irritants (ingestion of poison/overdose)
- Gastric gavage: gastric feeding
NGT insertion
Inserted by nurses, nursing students
Confirmed by XRAY before use upon placement
Placement checked (before tube feeding) by:
- Inserting air and auscultating “whoosh” over LUQ
- Checking gastric pH
- Suctioning green/yellow gastric content
NGT insertion procedure
- WIPE
- Measure and mark length to be inserted from tip of nose to earlobe and xiphoid
- Gather supples
- Position pt in semi-Fowler’s
- Lubricate end of NGT (3-4 in.)
- Guide up nostril while pt swallows/drinks water (epiglottis will prevent entry into trachea)
- Tape in place
- Check placement by XRAY
- Pt should be able to speak, minimal discomfort
Salem sump NGT
SHORT-term dual lumen NGT for gastric (1) decompression, (2) lavage, (3) medication delivery (NOT intended for lavage)
Blue “pigtail” allows air exchange to allow movement of fluid (do not knot to prevent leak; counterintuitive)
Typical adult size: 14-16 Fr.
Levin NGT
SHORT-term single lumen NGT for (1) gastric decompression, (2) lavage, and (3) gavage
Special feedings with infants
Preemies
Cleft lip or palate/structural deformities
Stiff lungs (makes sucking too exhausting)
Percutaneous Endoscopic Gastrostomy (PEG)
LONG-term feeding tube for BOLUS or CONTINUOUS feeding; it is inserted through the abdominal wall into the stomach, anchored by a balloon
MIC-KEY: flatter version of PEG; requires specific feed tubing that snaps onto valve
Used for: Head and neck CA, infants that cannot consume enough nutrients by mouth
Gastrojejunostomy/Jejunostomy tube
LONG-term, CONTINUOUS-only feeding tubes that decrease the risk for aspiration by keeping the esophageal-gastric sphincter (above stomach) closed; difficult/expensive to place (by interventional radiology)
Flush with sterile water to remain patent: in between meds., q8h if not in use, and q4h if continuous feeding
Types:
1. Gastrojejunostomy tube: three ports; G-port terminates in the stomach (suctions), while J-ports (FEED and Rx) terminate in the duodenum
- Jejunostomy tube: bypasses stomach directly into intestines
Kangaroo (patrol) pump
Controls rate of tube feed delivery (max 8 hr. feed volume; kangaroo bag changed q24h)
Meds. CANNOT be placed in bag
Must keep HOB at 30-45 deg. at all times to decrease risk of aspiration and V/
Gastric Residual Volume (GRV)
In continuous feeding, check GRV: if >1.5-2x the rate of tube feed delivery, re-instill residual, flush, and hold for 1 hr.
Re-check GRV before continuing feed
Stopcock/Lopez valve
Permits GRV-check or medication administration without disconnecting NGT/PEG from Kangaroo pump
Tube feed
Tube feed is hypertonic (pulls water out of cells) and may cause sudden D/ (d/t circulatory overload)
Types:
- Cans: used with kangaroo pumps
- Bottles with purple caps: inverted and hung on IV poles
Parenteral
Delivered intravenously (NOT through the GI tract)
Provides:
1. Fluids and electrolytes (NS, K+)
- Nutritional support (CPN/TPN or PPN; includes carbs., proteins, fats, electrolytes, vitamins, minerals)
- Medication administration (antibiotics)
Parenteral: lifespan consideration
Infants: strong vessel in scalp provides easy IV access
Older adults: rolling and collapsing veins
Both infants and older adults are at increased risk for fluid overload
IV solutions
- Isotonic: 0.9% NaCl NS and LR provides extra electrolytes (250-375 mOsm/L); replace lost fluids d/t: bleeding, V/, severe GI drainage
- Hypotonic: 0.45 NaCl NS (<250 mOsm/L); fluid shifts into cells; increase ICP, intravascular fluid depletion (CV collapse)
- Hypertonic: 3% or 5% NaCl NS (>375 mOsm/L); fluid shifts out of cells; decreases ICP, increases risk of circulatory overload, HTN, pulmonary edema (commonly used in ICU)
IV access
Butterfly: tiny needle used for intravenous access in infants and small children; blood donations
Angiocath: intravenous access in adults; needle punctures vein while plastic tubing hub remains
Peripheral IV access (PIV)
Used to infuse fluids, meds., draw blood, transfusions
Also called medlock/heplock/salinelock
Administration set
Primary: long-tubbing with spike and drip chamber that connects to PIV (changed ~q96h); priming: run air out of tubing
Roller clamp: adjusts rate of flow of fluid
Drip chamber: runs fluid to gravity
Piggyback (PB): short-tubing that connects to primary port to infuse meds., electrolytes (antibiotics, Mg2+; changed ~q24h)
Extension set: connects to the PIV to allow more ROM
Clave connector: “corks” end of PIV to prevent blood from flowing
Olser (banana) bag: replenishes lost vitamins and minerals (alcohol intoxication)
Nursing interventions
Set infusion rate and VTBI
Document I&O
Lab values
Factors affecting flow rate
- Height (raise bag to increase gravitational pull)
- Obstruction (kinks, flush with NS to identify clot)
- Access location
IV complications
- Infiltration: fluid into tissue; stop infusing, remove PIV, elevate extremity, apply heat/cold; S/S: Pain, burning, blister formation
- Phlebitis: inflammation of vein; stop infusion and find new access location; S/S: Erythema
- Infection: evident by erythema or purulent drainage
- Fluid overload
- Air embolism: prevented by priming; S/S: Chest pain, dyspnea
- Catheter break/damage
- CLABSI
IV orders
Maintenance: continuous
Bolus: all at once
KVO: keep vein open (low rate to keep line patent)
IV pumps
ALARIS: four channels (newer)
IMED: two channels (older)
Medication IV push (IVP)
Procedure (into PIV):
- Follow IVP chart procedure
- Flush to check/clear line
- Push medication at rate according to IVP chart
- Flush again at same rate medication was pushed
IVP into primary tubing: pinch tubing above primary tubbing port to ensure flushes/medication go towards pt
6 rights of medication administration
- Right pt
- Right medication
- Right dose
- Right time
- Right route
- Documentation
Tunneled central catheters
LONG-term CVADs placed in OR and confirmed with XRAY before used
Used for: Chemotherapy, transfusions, antibiotics, fluids, parenteral nutrition (CPN/TPN)
Types:
- Hickman: TRIPLE lumen with dacron sheath
- Groshong (more expensive): DUAL lumen with dacron sheath; used if allergic to heparin
Complete/Total parenteral nutrition (CPN/TPN) and Peripheral/partial parenteral nutrition (PPN)
Types of parenteral nutrition:
1. CPN/TPN: provides nutrition (>10% dextrose and/or >5% protein) through a CVAD
- PPN: provides nutrition (<10% dextrose and/or <5% protein) through a PIV or CVAD
Complications: Infection (d/t dextrose), circulatory overload (hypertonic solutions), hyperglycemia (monitor glucose by FS)
CPN/TPN and PPN: nursing responsibilities
Check order: ordered/infused on time; confirm type of nutrition
Administer in proper line
D10W on hand (if rxn to CPN/TPN) to wean-off parental nutrition and prevent hypoglycemia
Finger stick/Dexi per protocol (prone to hyperglycemia)
S/S of infection
Monitor pt and document
Autologous blood transfusion
Collection of own blood to be retransfused if necessary; guaranteed compatibility and eliminates risk of disease transmission
Overload risk still exists
Blood tubing
Blood bag and saline come together at filter to “weed-out” clots
Whole blood
500 ml bag of RBCs, WBCs, plasma, platelets; time-sensitive (infuse within 4 hr.)
Treat: Shock, hemorrhage (volume replacement)
Packed red blood cells (PRB)
250-300 ml bag of RBCs, plasma; 50% less volume (decreased risk for volume overload)
Treat: Anemia, moderate blood loss
Platelets
50-70 ml bag that increases platelet count to maintain normal coagulation; extremely time-sensitive (infuse via short tubbing within 15-30 min.)
Does NOT require ABO compatibility
Treat: Before invasive procedures, bleeding s/t thrombocytopenia (decreased platelet), bone marrow suppression
Fresh frozen plasma (FFP)
200-250 ml bag of plasma proteins, enzymes, electrolytes, nutrients (NO platelets) that increase clotting factors V, VII, VIII, IX, X
RAPID volume replacement for slow/active bleeds (infuse within 24 hr.)
Requires ABO compatibility
Treat: Bleeding s/t cirrhosis, hemophilia, bleeding d/t surgical procedure
Albumin
25, 50, and 100 ml bottles that increases plasma osmotic pressure to maintain and improve volume and CO; CANNOT be infused >1 ml/min.
Can cause fluid overload (thus diuretic may be ordered)
Do NOT require ABO compatibility
Treat: Hypovolemic shock, cirrhosis, burns, pulmonary/peripheral edema, ascites
ABO compatibility
A: can receive A, O (antigen A; antibody B)
B: can receive B, O (antigen B; antibody A)
AB (universal recipient): can receive AB, A, B, O (antigen AB; no antibody)
O (universal donor): can receive O (no antigen; antibody A, B)
*Two nurses are required for ABO compatibility sign-off
Blood transfusion: nursing responsibilities
WIPE
Consent form/blood requisition form/order/signatures
Prior to transfusion: VS ~q15m
Large bore IV (to prevent clots)
Premedicate
Infuse/monitor pt, VS per protocol
Document
Complications of blood transfusions
- Febrile rxn: stop and NHO; S/S: Fever, chills, HA; Tx: Antipyretic (reduces fever; Tylenol) and restart if reaction subsides
- Allergic rxn: stop and NHO; S/S: Flushing, wheezing, rash with itching, urticaria; Tx: Antihistamine/antipyretic and restart if reaction subsides
- Hemolytic rxn: RBC destruction, thus decreased oxygen-carrying capability, capillary destruction (and death); S/S: Flushing, fever, chills, HA, lower back pain, dyspnea, hypotension, hematuria, rigors, tachycardia; Tx: Stop, dilute with NS, VS, urine sample, return blood to bank, NHO, remain with/monitor pt, document
- Transfusion Associated Circulatory Overload (TACO) rxn: VOLUME-related issue d/t age or system; S/S: HTN, 3+ pulse, JVD, dyspnea, restlessness, confusion; Tx: Slow infusion, NHO, monitor I&O, diuretics
