N321 Exam 1 Enteral and Parenteral Nutrition

What considerations should we take with GI function in older adults?

- Poor dentition-- ability to eat certain foods

- Fine motor-- ability to feed self

- Access to care/mobility

- Slowed peristalsis and gastric emptying

What is the recommended cal/kg and cal/day?

- 20-35 cal/kg

- 1200-1500 cal/day minumum

Who are oral supplements appropriate for?

- People who can swallow and who's GI system is intake

- People with decreased oral intake and decreased appetite

When are high protein and high calorie foods/supplements given?

- With oral medication

- Between meals -- NOT as a meal supplement

What must you assess when determining the appropriate nutrition for your patient?

- Bowel sounds

- Gag-reflex

- Ability to swallow

- Fine motor skills

- Level of activity

When is Enteral Nutrition (EN) appropriate?

When a patient is unable to swallow or unable to meet nutritional needs by mouth, but GI tract is still in tact

What are some diagnoses that would be appropriate for EN?

- Anorexia

- Head and neck cancers-- impaired swallow

- Facial fractures-- impaired swallow

- ICU/critical care illness-- not awake enough to eat

- Neurological conditions-- post-stroke, unable to swallow, no gag-reflex

- Psychological conditions-- manic or schizophrenic

How is the type of tube feed determined for EN?

- Depends on the pt's needs

- Standard

- Protein-rich-- for sick or injured patients

- Calorie- rich-- sick of injured patients

- Low electrolytes

- High fiber-- patients at risk for constipation

- Diabetic

What are some types of feeding tubes?

- Nasogastric (NG)-- nasointestinal, orogastric-- Dobhoff

- PEG

- PEJ

What is a salem sump pump and what are the indications for use?

- A type of NG tube

- used short term

- Use strictly to DRAIN contents from the stomach

- Decompression of the stomach in presence of blockage, gastroporesis, paralytic ileus

- Removal of contents in OD

- May be connected to suction

- PLACED BY RN

What is a Dobhoff and what are the indications for use?

- A type of NG tube

- Short-term use (few months maximum)

- Used for feeds and medication administration

- Placed by MD or NP

What is the entry point of a gastrostomy tube?

Into the stomach

What is the entry point of a Jejunostomy tube?

Into the jejunum

How must placement of the dobhoff be verified prior to use?

XR!!

How can you prevent clogging a dobhoff tube?

- Regular flushes before and after administration of feed and medications

- Crush medications well

What assessments must you as the nurse consider when assessing NG tubes?

- Location-- has it moved?

- Patentcy

- HOB must be up

How can you as the nurse prevent aspiration in patients with NG tubes?

- HOB at 30 degrees or higher

- During and 2 hours after feeds-- or always for continuous feeds

- Pause the feed if you need to lie them flat for any reason

- Confirm placement

What other nursing care must be done on patients with NG tubes?

- Oral hygiene

- Skin/lip care

- Aspiration prevention

- Maintaining patent tube

- Monitoring location of tube-- look for change in movement

What are some risks that patients with feeding tubes face?

- Dry mouth

- Oral infections

- Bacterial infections from tube feed and lack of aseptic technique

Why does the G-tube have a higher risk for aspiration?

- Termination in the stomach puts patient at risk for aspiration and reflux

- Must check residuals before feeds

How is aspiration prevented in patients with G-tubes?

- Checking residuals before feeds

- HOB up

How soon after placement can you use G/J-tubes and how will you know when it is ok to use?

- 24-48 hours after placement

- Will need an order

What is the rate of feed in G-tubes?

Bolus or continuous

What is the rate of feed of J-tubes?

Continuous feeds only

What is the aspiration risk with J-tubes?

- Low

- Placed lower in GI-- less risk of aspiration

- Do not need to check residuals

What feeding tube must you check residuals?

G-tubes

How should you as the nurse interpret residuals?

>250mL on 2 consecutive residual checks— start promotility drug

<500mL— likely still give residual and tube feed

>500mL— hold tube feeds and notify physician

Why do you want to re-feed the residual?

If you do not re-feed you risk causing an electrolyte imbalance

What type of education must you give the family of patients with feeding tubes?

- They cannot have ANYTHING PO

- Should visit and come keep the patient company

- Help them understand why the patient has a tube placed

- Discuss important of skin care around insertion sites

Why is skin care important with G/J-tubes?

- Protect from infection

- Keep covered in dressing and keep it clean as it heals

- Look for s/s infection

What are the first steps a nurse should take when caring for a patient with a feeding tube?

- Mark tube exit (if NG)

- Document placement

- Make sure tube is secured-- bridle or tape

What must be done prior to initiating feeds?

XR to confirm placement

What type of feed administration best mimics real eating?

Bolus

When is continuous feed appropriate?

- Critical care patients

- Sick patients with higher caloric needs

When is it ok to flush with NS?

If the patient is on suction (sump)

What are some ways to unclog an NG tube?

- Clog buster-- enzymes

- Gingerale and cranberry juice

When should you flush tube with water?

- Before and ater each tube feed

- Every 4-6 hours on continuous feed

- To prevent clogging of tube and to meet patients hydration needs

How are bolus feeds generally administered?

To gravity

How are continuous feeds generally administered?

Infusion pump

How often must the tubing/bag be changed for EN?

- Every 24 hours

- Or if you find an unlabeled bag-- change it

What must you verify before hanging a feed?

Right patient, route, tubing and formula

What temperature should tube feeds be?

Room temp

What must be recorded everyday for EN patients?

- WEIGHT

- Pre-albumin

What might too fast of weight gain indicate?

Edema

What patients are at high risk for tube-dislogment?

Confused patients

Patients who move around a lot

What should you ask pharmacy for if you have a patient with a tube feed?

Liquid meds if possible!

What type of technique should be used when preparing and delivering EN formula?

Aseptic

What are some examples of aseptic technique when handling EN formula?

- Hand hygiene

- Wear gloves when handling tubing

- Avoid touching tops, openings and ends

What type of pills cannot be crushed for tube feeds?

- Enteric coated

- Long acting/sustained release

- Capsules

What are some of the potential complications related to EN?

- Aspiration

- GI intolerance

- Dehydration

- Constipation

- Skin irritation/infection

- Dislodgment of tube

- Glucose intolerance

What would be some causes of aspiration with EN?

- Improper placement

- Improper installation of medications

What would be some s/s of GI intolerance with EN?

- N/V

- Stomach pain

- Watch for this when you start a new formula

What would be some causes of dehydration with EN?

- Wrong formula

- Too much protein

- No enough fiber

- Not getting enough flushes

What would be some causes of constipation with EN?

- Not enough fiber

- Slow gastric emptying

- Wrong formula

What would be some s/s of skin irritation with EN?

- Redness around insertion site

- Redness or irritation under tape/dressing

- Caused by poor skin care

What would be some causes of dislodgement with EN?

- Confused patient pulls out

- Accident

- Poor skin healing around insertion site

What would be some causes of glucose intolerance with EN?

- Hyper-- inappropriate formula

- Hypo-- not getting sufficient nutrition

How can dehydration be prevented in EN patients?

- Giving enough flushes

- Adding IV hydration as needed

What is an important teaching component for patients on EN in the hospital?

They will be getting regular BG testing to make sure the nutrition is appropriate

DM patients will be getting checked more than usual

What is the order of actions when administering tube feeds?

- Check patency of tube-- use sterile water

- If patent, check residual

- If residual is >500mL stop and call M

- If residual is <500mL give back to pt and start feed

- Flush with water

When is PN indicated?

When the Gi tract is not functioning properly

What are some examples of occurrences when PN is preferred?

- Abdominal surgeries

- Bowel obstruction or ileus

- GI malignancies

- Severe anorexia

- Severe malabsorption

- Short gut syndrome

- Trauma

- Uncontrolled, chronic D/V

What is the MOA of PN?

- Intravenous administration of feeding formula

- Made by pharmacy

If a patient arrives with uncontrolled N/V, what should you as the nurse do first?

- Find cause

- Treat with D5 temporarily

- If lasts 3-5 days, PN is appropriate

How do HCPs know what the PN needs of the patient are?

- Daily labs

What type if IV is preferred for PN administration?

- Central line

- Large peripheral IV-- 16G or 18G

What are the downsides of PN?

- Greater infection risk

- Greater risk for nutritional imbalances

- Greater risk for BG issues

- Expensive

Why do you want to avoid administering PN through peripheral IVs?

Can be very irritating to the vein

What patients would high fat PN be contraindicated?

Patients with bone fractures

Patients with hyperlipidemia

Patients with bleeding disorders

Patients with pancreatitis

What patients may not be able to tolerate PN?

Patients with renal and liver issues

What s/s are reported with higher fat PN formulas?

Nausea

How can you adjust PN administration so renal patients can tolerate?

Give in intervals

What are you concerned about with your initial administration of a new PN feed?

Adverse reactions

- N/V

- Hyper/hypoglycemia

- Hypersensitivity reaction

When is a peripheral line indicated for PN?

- Less viscous formula

- Short-term

- Lower nutritional needs

- Supplementation for poor oral intake

- When risks outweighs benefits with central line placement

What are the risks of using a peripheral line for PN?

- Phlebitis

- Irritation to vein

- Fluid overload

- infection-- less blood flow, shorter catheter

When is a central line indicated for PN?

- More viscous formula

- Long-term

- High nutritional needs

What are the risks of using a central line for PN?

- Infection-- close to heart, lower likelihood

- Dislodgment

- Thrombosis

- Hemorrhage

- Air embolism

- Pneumothorax

What technique must you use any time you manipulate a central line?

STERILE TECHNIQUE

How often must tubing be changed for PN?

Every 24 hours

How is PN administered?

Infusion pump

What are some metabolic issues related to PN?

- Hypo/hyperglycemia

- Hyperlipidemia

- Impaired renal or liver function

- Electrolyte, vitamin or trace minral deficiencies

What can you do to treat hypoglycemia between feeds in your patients?

D50 if there is a delay between feeds

How often do central line caps need to be changed?

Every 24 with tubing

How often will you be taking BG the first 2 days of new PN formula?

every 4-6 hours

What daily measurements need to be taken on patients on PN?

- Labs-- BMP, BG

- Weight

- I&O

Who is the primary decision maker of PN formula?

Pharmacy

Who is the primary decision maker of EN formula?

Nutrition