Chapter005tubefeed

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 5Advanced Nutrition Skills

Chapter 5Advanced Nutrition Skills



OrgansOrgans

• Mouth- Saliva( deglutination)+Teeth-(mastication)=bolus

• Tongue-uvula -

Esophagus-peristalsis-cardiac sphincter

• Stomach- 1-4 hrs. to break down→ chyme

• Small intestine- absorbs nutrients & fluid

• Large intestine-absorbs H2O-rectum-anus – e-coli

• Liver- breaks down toxin, make bile

• Gall bladder-store bile

• Pancreas


Disorders of the GI system:Disorders of the GI system:

• Inflammatory bowel disease (IBD) irritable bowel syndrome (IBS). It includes: Crohn's disease and ulcerative colitus.

• Crohn's disease occurs anywhere in GI tract & affects every layer of tissue.

• Ulcerative colitus typically occurs in the colon & rectum & affects only the innermost layer of tissue



UlcerUlcer


Bulimia Bulimia


AnorexiaAnorexia


Obesity-Obesity-

• Overweight: over ideal body by < 20%.

• Obese: over ideal body weight by >20%.

• Morbidly obese: over ideal body weight by> 100 lbs. severe threat to health & life.


• Diarrhea • Constipation


TermsTerms

• NG

• G-tube

• TPN

• Aspiration

• Residual

• Placement

• Bowel sounds

• Auscultation

• peristalsis


Enteral NutritionEnteral Nutrition



Reasons for an NGReasons for an NG

• Remove fluid from abdomen to decrease n/v, gas or obstruction

• Dx. Diseases

• Clean out stomach (overdose)

• Provide feeding

• Bowel obstructions

• Surgery of stomach/intestines


Nasogastric or Nasointestinal TubeNasogastric or Nasointestinal Tube

• Enteral nutrition/ tube feeding- is formula-like fluid delivered through a tube that is in nose

• Naso-gastric tube- nose to stomach

• Naso-intestinal tube-nose to small intestine


Risks Associated With Nasogastric/Nasointestinal TubesRisks Associated With Nasogastric/Nasointestinal Tubes

• Used short time b/c irritating to nose & throat

• Easily displaced if pt. coughs, vomits, or pulls on the tube


Risks Associated With Nasogastric/Nasointestinal Tubes (cont.)Risks Associated With Nasogastric/Nasointestinal Tubes (cont.)

• Sores inside the nose

• Irritation & crusting of mucus around the nostrils

• If tube goes into the lungs- difficulty breathing, aspiration pneumonia, respiratory arrest, or death


Ways to Confirm Proper Tube Placement-Check placementWays to Confirm Proper Tube Placement-Check placement

• Measure length of tube outside the nostril - end of the tube. Make sure length has not changed since the tube inserted.

• Aspiration of stomach content

• Air bolus


QuestionQuestion

Tell whether the following statement is true or false.

It is not important to check naso-gastric tube placement after insertion.

A. True

B. False


AnswerAnswer

B. False

It is very important to always check placement of the naso-gastric tube. If the naso-gastric tube is not in the proper place, patient could aspirate feeding, causing coughing, discomfort, pneumonia, and even respiratory arrest.


Gastrostomy or Jejunostomy Tube Gastrostomy or Jejunostomy Tube

• A gastrostomy tube ( G-tube) surgically inserted into the stomach through abdomen (a percutaneous endoscopic gastrostomy [PEG] tube)

• A jejunostomy tube- inserted into the jejunum (part of the small intestine) surgically


Gastrostomy or Jejunostomy Tube (cont.)Gastrostomy or Jejunostomy Tube (cont.)

• Long term use

Check for redness or drainage

Clean with mild soap & water,


Three Ways of Administering Enteral Nutrition Three Ways of Administering Enteral Nutrition

• Syringe: inserted feeding tube & formula poured into syringe.

• Feeding bag: feeding bag hangs on an IV pole. (gravity)

• Feeding pump: The tubing from the feeding bag is threaded through the feeding pump



QuestionQuestion

Which feeding tube is inserted into the small intestine through a small incision?

A. Gastrostomy

B. Jejunostomy

C. Nasogastric

D. Endotracheal


AnswerAnswer

B. Jejunostomy

The jejunostomy tube is inserted into the jejunum (part of the small intestine) through a surgically made opening in the abdomen.


Schedules for Enteral Feedings Schedules for Enteral Feedings

• *Bolus intermittent feeding: receive a large amt. over a short amt. of time.

• *Continuous feeding: receives formula constantly, 20 to 24 hrs/ day; use a feeding pump


Packaging for Enteral Feeding Formulas Packaging for Enteral Feeding Formulas

• Cans

• Packets

• “Ready to hang” bottles


Possible Complications of Enteral FeedingPossible Complications of Enteral Feeding

• Aspiration

• Heath care–associated (noscomial) infection

• Dehydration

• “Dumping syndrome”

• Contamination

• Clogging of tube

• Security of tube

• Kinked tube


Report to the Nurse ImmediatelyReport to the Nurse Immediately

• Coughing or wheezing

• Diarrhea or constipation

• Difficulty breathing

• Fever

• Low reading on pulse oximeter

• Abdominal pain or bloating

• Cyanosis

• Dry mucus membranes

• Nausea or vomiting

• Decreased or very concentrated urine


TF rulesTF rules

• If bolus give over 10-20 min.

• Elevate HOB 30 degrees during & @ least 30 min after feeding

• Check placement- before feeding

• air bolus- 10-15 cc air

• aspiration of GI contents

• If intermittent check residual – if > ½ last feed call RN

• Monitor glucose/dip all urines


TF rules con’tTF rules con’t

• I/O

• Mouth care q 2 hrs

• Secure tube

• Give TF @ room temp- cold causes cramping/diarrhea

• Hang TF no more than 24 hours

If con’t mix 8 hours at a time

Clean bag after each use

Hang new bag/tubing q 24 hours


TF rules con’tTF rules con’t

• Irrigate (flush) before & after use

• Clamp NG when not being used (decrease clogging)

• Clean g-tube: soap/ h2o or ½ peroxide/h20


ChartingCharting

• 250 cc TF given @ ½ str. ( 125 cc TF/125 cc H2O) per NG per Dr. Jones. Placement verified with 5 cc air bolus & aspiration of GI contents. No residual, elevated HOB to 30 degrees. Pt. tolerated s n/v. M Snyder RN notified of infusion. Instructed pt to keep HOB elevated @ 30 degrees for ½ after feeding.


NG chartNG chart

• D/C NG per Dr Jones. Emptied gastric suction for 250 cc dark green foul smelling secretions. Guiac positive. Notified S. Smith RN pt. c/o nausea. Instructed pt. to take sips of water & call RN if vomiting occurs.


Total Parenteral NutritionTotal Parenteral Nutrition


How TPN Differs From Enteral Nutrition How TPN Differs From Enteral Nutrition

• TPN bypasses digestive tract & delivers nourishment directly to bloodstream & isn’t digested.

• TPN-administered through central line into one of the two large veins that empty directly into the heart.


How TPN Differs From Enteral Nutrition (cont.)How TPN Differs From Enteral Nutrition (cont.)

• TPN -a solution that contains nutrients in their smallest form.

• Patients who receive TPN are very ill, injured, or may be recovering from surgery, especially gastrointestinal,& may not be able to tolerate food in the digestive tract.


Nursing Assistant’s RoleNursing Assistant’s Role

• Check dressing over CVL is clean & dry

• Notify the RN if drsg becomes wet, soiled, or loose

• Monitor the patient’s blood glucose levels


Monitoring Glucose LevelsMonitoring Glucose Levels

• TPN very concentrated & contains high glucose

• Delivered directly into bloodstream, causing difficulty monitoring & regulating the blood glucose level

• Monitored q 6 hrs

• Pts taken off TPN should continue to have their glucose levels checked for hypoglycemia


QuestionQuestion

What tests are performed on a regular basis on all glucose meters?

A. Pressure tests

B. Glucose tests

C. Quality control

D. Fluid levels


AnswerAnswer

C. Quality control

Quality control tests are performed regularly on all blood glucose meters to ensure that the readings they give are accurate.


GuidelinesGuidelines

• Definitions:

Continuous- TF runs all

the time

Bolus: (intermittant) one time feeding

• Shift times for I &O

Day shift:

after 0600- 1400

Evening shift:

after 1400-2200

Night shift:

after 2200-0600


MATHMATH


How to find total amount of food How to find total amount of food

• Amount in a shift?

Amount order per hour x hours infused= total shift amount

Example: 30 cc/hour x 8 hours= 240 cc


Total amount in 24 hoursTotal amount in 24 hours

• add amount infused/per shift together

• example;:

• Days- 30 cc/hr x 8 hours= 240 cc

• Evenings- 25 cc/hr x 8 hours= 200 cc

• Nights- 50 cc/hour x 8 hours= 400 cc

•Total amount = 840 cc/24 hr


Tube feeding StrengthsTube feeding Strengths

Some Tube feeds are too strong for a patient therefore they are diluted as follows:

¼ str.=.25

½ str.=.50

¾ str.= .75

* Only mix enough for a shift or the amount you are currently giving

• To calculate str. Multiply amount needed by str.

• Example:

40 cc/hour x 8 hr=320cc

320 cc x .25 str=80ccTF

320cc-80 ccTF=240H20

For this you would mix80 cc TF & 240 H20 for a total of 320 cc total feed for your 8 hour shift


Intake and Output ( I&O)Intake and Output ( I&O)

• Total infusion :

• If it is a bolus you do not X by any hours

• If it is continuous infusion X by # of hours infusion is running in your shift ( if TF is shut off for 2 hours, you X by 6 hours instead of 8)

• Do not forget to add flushes


Bolus (intermittant) feedingsBolus (intermittant) feedings

• Bolus feeding is a one time feed- it is generally a small amount

• The order may read give 1 can of ensure

• 1 can = 240 cc

• So you would give 240 cc for that feeding

• If the order says give 300 cc at ¾ str. You need to dilute

• Example:

• 300cc x .75=225 cc TF

• 300cc- 225 TF=75 ccH2O

• You give 225 cc TF mixed with 75 cc H2O


FlushesFlushes

• Sometimes the TF order will include an order to flush NG with water before & after TF infusion- remember to calculate this into the intake when doing I&O

• Example: Give 50 cc bolus of pedialyte per NG flush with 10cc H2o before and after infusion

• What is the total intake:

• 50cc TF + 10 cc H2O bolus before + 10 cc H2O bolus after= 70 cc total intake for shift

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Chapter005tubefeed