Oral, Enteral and Parenteral nutrition

Malnourished patient experience

increased length of stay in hospital

more complications during their stay

• infection rates

• mortality rates

what can we do?

• nutritional screenings

• conduct mealtime rounds

• oral care/ denture care

• encourage visits during meal times

• ask family to bring preferred foods

• provide nutritious snacks

diets

• clear liquid (CL)

• full liquid (FL)

• pureed

• mechanical soft

• diet as tolerated

• low-residue

• high fiber

• restricted fluids

• sodium restricted

• low fat (fat-modified)

• diabetic (ADA)

Clear liquid

CL diet

sprite, tea, coffee → light can pass through it

Full liquid

FL diet

milk → opaque

diet as tolerated

DAT or advance as tolerated

start slow build up to normal

low residue

opposite of high fiber

high fiber

increase water intake

Aspiration

misdirection of secretions or gastric contents into the larynx or lower respiratory tract

risk factors for aspiration

position, dysphagia, stroke, head.neck cancer, head trauma, dementia

parkinson’s disease, medical interventions that compromise the gag reflex

tolerance of oral nutrition

• frequent drooling

• loss of food from mouth

• pocketing food

• chocking/coughing when swallowing

• gurgling or wet sounding voice quality

• sensation of food that is “stuck”

prevent a patient from aspirating

1) sit patient up

2) small/slow bites

3) liquids between bites

4) diet modification

5) make sure they swallow and not pocket the food

6) suction available

oral nutrition: documentation

amount of diet-%

type of diet

amount of liquid - use mL

how they tolerate it

enteral nutrition

• nutrition delivered tube in gastrointestinal (GI) tract

• placed in stomach or small intestine through nose or abdominal wall

N- nasal

O- oral

G- gastric

D- duodenum

J- jejunum

T- tube

percutaneous endoscopic gastronomy

PEG tube

surgical placed long term

Considerations

type of tube and placement vary per patient condition

• duration of treatment

• GI anatomy/emptying

• aspiration/reflux risk

nasal tubes

• sinusitis/ otitis

• vocal cord paralysis

• pressure injuries to nose and sinuses

enteric (rather than gastric) - reduces Rx of aspiration

Confirm placement via

chest x-ray before administer feeding or medications

assessment before placing NGT

Hx of deviated septum, nosebleeds, oral facial surgery

anticoagulant therapy or coagulopathy

gag reflex (aspiration risk)

mental status

lung sounds- baseline

bowel sounds

physician order

complications during the insertion and maintenance of a feeding tube

incorrect placement

gag reflex → vomit

leave HOB >30 degrees at ALL times

When do we verify placement?

before administering formula, medication, water, or anything else into the tube

at least q 4-6hrs

How do we verify?

1. Monitor external length- mark

2. GI Aspirate- pH, color, quality amount

• 5.5 or less- gastric

• 6.0 or more- small intestine or pulmonary

measuring length for ng tube

tip of nose to earlobe to xyphoid process plus 4 inches

irrigating a feeding tube

• clear & clean lumen q4-6 hrs

• 30ml sterile water

  • change bottle 7 syringe q 24hrs

• before, between, and after medication

• before and after INT (bolus) feedings

intermittent (bolus)

cans

“gravity” tubing (30-45 min)

flushing before & after is important

continuous (via pump)

controlled rate

prevents bloating, cramping, diarrhea

auto-flush/feed

hold to assess residuals & flush q 4-6 hrs

0-250 ml

return residual and continue feeding

250-500ml

do NOT return the residual, continue the feeding- monitor

>500ml

do NOT return the residual, stop the feeding, and call the provider

What if it won’t flush?

curled enteral formula/Improperly crushed medications

if liquid form of medication is available, request it

What do we do about it?

• unclamped

• change positions

• warm water- soak 5-10 min

• enzyme from pharmacy

Care of a gastrostomy or jejunostomy tube

• soap and water (or saline) from stoma outward

• assess skin

• rinse & pat dry

• dressing goes over disk (on top of bumper)

• combination tubes- allow for jejunal feeding and gastric decompression

Documentation

I&Os

NG tube gastric decompression

removing gastric secretions

instillations/solutions

different type & size of tube

• double lumen (vented)

• singel lumen (nonvented)

suction set up

continuous or intermittent

strength of suction

• high

• med

• low

LIS

low intermittent suction

LCS

low continuous suction

removing NG tube

(MD order)

disconnect & clear line with 20 ml air

towel on chest

patient hold breath while you pull tube out slowly & steadily

inspect tube for intactness

key points for enteral tubes

ensure placement- assess for migrations

keeping HOB 30 degrees of above

protect line/securement

assess bowels/nutrition/I&O

assess skin/mucosa around tube for inflammation, blistering & excoriation

How often is the bag for enteral feedings changed?

every 24hr

the nurse has just inserted a nasogastric (NG) feeding tube into a patient. What should the nurse do to ascertain that the tube is the stomach definitively?

obtain a chest x-ray

the nurse is checking gastric residual on a patient who has a continuously running tube feeding. She finds that the patient has a 600ml residual volume. How should the nurse respond?

stop the tube feeding

the nurse is caring for a patient who is receiving continuous tube feedings. What must the nurse do to care for this patient

verify tube placement every 4 to 6 hours with visualization of length, pH, and assessing residual

purpose of parenteral nutrition (PN)

provide nutrition intravenously for patients who have significant GI dysfunction

energy sources:

• amino acids, glucose, lipids, electrolytes, minerals, trace elements, vitamins, water

candidates for PN

small bowel surgery. Paralytic ileus/obstruction

trauma to abdomen/head/neck

severe malabsorption/malnutrition

intolerant of enteral feedings

nonfunctional GI tract, pre op bowel rest

risk with PN

1. Pneumothorax

2. Air embolism

3. Localized infection

4. Catheter-related sepsis or bactermia

5. Hyper-hypoglycemia

PPN- peripheral Parenteral Nutrition

• thought peripheral IV

• mild-mod malnutrition up to 1 week

• lesser osmolality than TPN

TPN- Total Parenteral Nutrition

• Central line (subclavian- triple lumen cath)

• PICC (perp. inserted central cath)

• usually ordered with lipids