E3 - Oral, Enteral, and Parenteral Nutrition

Things that malnourished pts. experience

-longer stays in the hospital

-more complications during their stay → infection rates, mortality rates

(when compared to well-nourished pts.)

What can we do to help malnourished pts.?

-Nutritional screenings

-Conduct mealtime rounds → assist patients PRN

-Oral care / Denture care

-Encourage visits during meal times

-Ask family to bring perferred foods

-Provide nutritious snacks

Progressive & Therapeutic Diets

Clear liquid (CL diet)

Full liquid (FL diet)

Pureed

Mechanical Soft

Diet as Tolerated (DAT or Advance as Tolerated)

Low-residue

High fiber

Restricted fluids

Sodium restricted (less salt)

Low fat (fat-modified)

Diabetic (ADA)

Aspiration

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

Swallowing requires coordination of what

Cranial nerves, Tongue, Pharynx, Larynx, Jaw

Why might a pt. be on a restricted fluid diet?

CHF - fluid overload, heart cant pump well

*they also may be on a Na+ restriction → Na+ follows water

Why might a pt. be on a sodium restricted diet?

Conditions like hypertension, heart failure, or kidney disease to reduce fluid retention and lower blood pressure.

2 components of a heart healthy diet

Low sodium

Lower fat (esp. trans fats) = lower cholesterol

(reduces Coronary Artery Disease)

Why is aspiration a concern

can cause airway obstruction, aspiration pneumonia,

Why should we NOT feed stroke pts until we do a swallow study

to assess their ability to safely swallow and prevent aspiration.

Why should we be careful feeding pts. with neuromuscular disease

to avoid swallowing difficulties and reduce the risk of aspiration-related complications

Ideal position for a pt. to eat

HIGH Fowler’s

Risk Factors for ASPIRATION

Dysphagia = difficulty swallowing

Stroke

Head/Neck CA = tumor obstructions

Head Trauma = impacting structures, brain damage?

Dementia

Parkinson’s Disease

Medical Interventions that compromise gag reflux (see additional slide)

Medical Interventions that compromise the gag reflux

-Esophagogastroduodenoscopy (EGD)

-Mechanical Ventilation

-Sedation

Conditions that result in slowed eating and food being left in the mouth may cause…

Aspiration

Evaluate Pts. Tolerance of Oral Nutrition

Frequent Drooling

Loss of food from mouth (loss of motor function)

Pocketing food (dementia?)

Choking/coughing when swallowing

Gurgling or wet sound voice quality

Sensation of food being “stuck”

What do we do if we suspect a pt. is at risk for aspiration, choking, etc?

1) Make pt. NPO

2) Get an order for the Speech-Language Pathologist (SLP) → barium swallow (Dx test), EDG

6 Techniques to Prevent a Pt. From Aspirating

1) High fowler’s

2) Small amounts of food

3) Ensure they are swallowing, not pocketing, the food

4) Thickening Liquids

5) No straws w/ dysphagia

6) Alternate food and water

When feeding stroke pts., (after theyve been NPO and had a bedside swallow study), how should we feed them?

Feed them on the side NOT affected by the stroke

Documentation of Oral Nutrition

-Amt of diet %

-Type of diet

-Amt of liquid

-Require assist? → as the nurse, it is OUR responsibility to make sure a pt receives assistance if needed to successfully eat an adequate amount of food

-How they tolerate it? → choking, changes in voice quality, etc.

Can you document a PCA to feed an unstable pt (stroke, NPO, etc.)?

NO!

Enteral Nutrition / Feeding

Nutrition delivered through a tube in the GI tract

Where are enteral nutrition tubes typically placed

In the stomach or small intestine through NOSE or ABDOMINAL WALL

NGT

nasal gastric tube

OGT

oral gastric tube

OJT

oral jejenum tube

ODT

oral duodenum tube

Percutaneous Endoscopic Gastrostomy

PEG tube = incision right into the abdominal wall to insert a feeding tube directly into the stomach, allowing for long-term nutritional support.

*most invasive as its surgically inserted

Sites of Enteral Nutrition

N = nasal

O = oral

G = gastric

D = duodenum

J = jejunum

T (at the end) = tube

Types of feeding tubes and placement vary per pt condition

Pts. with an aspiration may have a NG tube where in the GI tract

Lower in the GI tract (stomach, SI, etc.)

NG or OG tubes are higher risk for aspiration pts bc they fall where

HIGHER in the GI tract

Tubes LOWER in the GI tract are beneficial for pts at aspiration risk

as they provide a safer alternative for feeding, reducing the likelihood of aspiration.

Before administering feeding or medication we CONFIRM PLACEMENT WITH A …. ??????

“gold standard”

X-RAY!!!!!!!

*mark document and depth

Factors we consider when placing an NG tube

Duration of Tx

GI anatomy/emptying

Aspiration/reflux risk

Nasal Tubes

Sinusitis/otitis

Vocal cord paralysis

Pressure injuries to nose and sinuses

Enteric tubes (rather than gastric) reduces risk of…

Aspiration

Assessment before placing an NGT

Hx → deviated septum, nose bleeds, oral facial surgery?

Anticoagulant therapy / coagulopathy

Gag reflux (aspiration risk)

Mental Status

Lung sounds - baseline

Bowel sounds

• Must have Physician Order

What is the most common complication of blindly inserting a NG or NE tube

Improper placement in the esophagus or pulmonary system

*XRAY CONFIRMATION

-pH

Ideals for Inserting a Feeding Tube

Guide wire → small bore 8-12fr, Leave stylet in place UNTIL XRAY, do not reinsert stylet after partially or fully removed

-High fowler’s position

-Aspirate for: pH amt, color (yellow/green), quality

*Arrange a distress signal with your pt.

Inserting a Feeding Tube for pts with a gag reflux

Gag reflux can lead to VOMIT

-Do not advance tube while pt is coughing or talking

-Allow rest

*Leave head of bed (HOB) >30 degree at ALL times 45 degree is preferred

Once we confirmed a feeding tube’s placement with an XRAY, what do we do next?

Migration → measure & mark with indelible ink or tape

(ensures proper length)

Gi Aspirate: pH, color, quality, amount

When do we verify feeding tube placement?

Before administering formula, meds, water, or anything else into the tube

*At least q 4-6 HRS

Ideal pH for gastric feeding tube

<5.5

Ideal pH for small intestine or pulmonary feeding tube

6.0+

Steps to measure length + depth of NGT insertion

1) Xyphoid process

to

2) Earlobe

to

3) Tip of nose

PLUS +4 INCHES (or 10 cm)

What is there is no “return” with a feeding tube?

It is OK to administer food/meds if…

-been confirmed by CXR
-No risk factors for dislocation

-On appropriate marking

-No respiratory distress

It is NOT OK to administer if..

-unconfirmed by CXR

-you suspect migration → notify provider, get order for another CXR

Irrigating a feeding tube

Clear & cleans lumen q 4-6 hrs

30mL of sterile water → change bottle + syringe q24 hours

-Before, between, and after medications

-Before and after INT (bolus) feedings

*Slow and gentle, do not force!

“Free water” in a feeding tube is used for..

Hydration

Gastric feedings tubes have a higher risk for

Aspiraiton

Duodenum feeding tubes have a lower risk for

Aspiration

Appropriate techniques for administering enteral formulas

-Room temperature

-Change tubing/bags at least q 24 H (if not with every use)

make sure to put date/time/inital

-Shake well

-Residuals: q 4-6 hrs *gastric emptying

Ongoing assessments: lungs, bowel, nutrition: electrolytes and weight

Using an intermittent (bolus) feeding tube

-Cans

-Gravity tubing (30-45 mins)

-Flush before and after!

Using a continuous (via. pump) to administer enteral formulas

-Controlled rate

-Prevents bloating, cramping, diarrhea

-Auto-flush/feed?

-Hold to assess residuals and flush q 4-6 hrs

Gastric Residual Volumes (GRVS)

0-250 mL : return the residual and continue feeding

250-500 mL : do NOT return the residual, continue the feeding *Monitor

500+ mL : do NOT return the residual, stop the feeding, and CALL THE PROVIDER!

What if syringe wont flush???

Formula/Pill may be curdled or improperly crushed

→ Request liquid form of med if possible!!

Checklist if a syringe wont flush

1) is tubing UNCLAMPED?

2) Change pt. position

3) Warm water → soak for 5-10min, gentle back and forth

4) Enzyme from pharmacy → do not use soda or hot liquids

*If no nursing interventions work, notify the MD

Care of a Gastrostomy / Jejunostomy Tube

Soap and water (or saline) from stoma outward

Assess Skin

Rinse and pat dry

Dressing goes over disk

Total Peripheral Nutrition (TPN) must be done through a…

Central Line

Combination GJ Feeding Tubes

Allow for jejunal feeding and gastric decompression

-different ports: jejunum port, gastric port

Documentation w/ Feeding Tubes

Tube type, anatomical location

Residual → color, quality, amt, etc.

Type & Amt of each feeding (intake!)

Type & Amt of flush/irrigant (intake!) - patency of tubing

Lung asmt/Bowel asmt - (output) diarrhea?

Tolerance of procedure and feeding - (output) emesis?

pH test result

Any complications

*RECORD I&Os

Using an NG tube for gastric decompression

Remove gastric secretions

Instillation of meds/solutions

Different type and size of tube (14-16fr)

Salem Sump - double lumen “vented”

*used for gastric decompression

• one for gastric contents (main clear lumen attached to suction or clamped)

• one for air vent (blue “pigtail”) → never clamp, use for suction or irrigate. keep above level of stomach

Levin - single lumen “non-vented”

used for gastric decompression

2 types of NG tubes used for gastric compression

1) Salem sump = double lumen (vented)

2) Levin = single lumen (non-vented)

Suction set up

• Continuous or Intermittent?

• Strength of Suction: high, med, low?

• low suction = 20-40mmHg

• LIS = low intermittent suction, LCS = low continuous suction

Documentation Example for NGT suction

4/25/19 0810  NGT to LIS 20mmHg, secured to nose with tape at 23”.  Gastric contents thick greenish-brown.  No c/o nausea at this time.  Emesis basin w/i reach.  Adheres to NPO status.  Ice chips for comfort per MD order.-----------------------------------Ssmith, SN, TTU

When to document I&O’s

Output: gastric contents in suction canister

• at end of shift, lvl marked with sharpie w/ date, time, initials

Intake: any flushes before, during, and after meds

Removing an NG tube

• must be ordered by a MD

• disconnect and clear line w/ 20mL of AIR

• towel on chest

• have pt hold their breath while you pull tube out slowly and steadily

• inspect tube for intactness

Documentation Example after removing an NG tube

•9/24/18 1035  NGT removed at this time, tip intact.  Patient tolerated well.  Provided facial & oral hygiene.  No signs of skin breakdown.  Will continue to monitor tolerance & BS.------------------------------Ssmith, SN, TTU

Key Points for Enteral Tubes

• ensure placement - assess for migration (resp status)

• Keep HOB >30 degrees

• Protect the line / secure it

• Assess bowels, nutrition, I&O (flushes, feedings, meds, suction, residuals, etc.)

• Assess skin and mucosa around tube for inflammation, blistering, and excoriation

How often is the bag for enteral feedings changed

q 24 hrs

The nurse has just inserted a NG tube into a pt. What should the nurse do to ascertain that the tube is in the stomach definitively?

Obtain x-ray

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

Verify tube placement q 4-6 hrs with visualization of length, pH, and assessing residual

What is the purpose of Parenteral Nutrition (PN)

provide nutrition intravenously for pts. that have significant GI dysfunction

Energy sources given via. Parenteral Nutrition

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

Patients who are candidates for parenteral nutrition

• small bowel surgery

• paralytic ileus / obstruction

• trauma to abdomen, head, neck

• severe malabsorption or malnutrition

• intolerant of enteral feedings

• nonfunctional GI tract = severe diarrhea, irritable bowel disease, moderate to severe pancreatitis

• pre-op bowel rest

Risks associated with Parenteral Nutrition

1) Pneumothorax

• catheter tip enters pleural space, lung collapses

2) Air Embolism

• IV tube disconnected or opened without being clamped

3) Localized Infection

• poor aseptic technique during insertion or dressing care

4) Catheter-Related Sepsis or Bacternia

• catheter hub contaminated- ineffectively cleaned

5) Hypo/Hyperglycemia

• if PN runs out, start D5W

Monitoring Procedures for pts receiving PN

• I&O’s q 8 hrs

• Routine vitals

• Weight 3x weekly

• FSBS q 6 hrs

• CBC, CMP, and serum proteins daily until stable

What are we monitoring when look at CBC in pts receiving PN

-Hgb, Hct

-RBC

-WBCs / lymphocytes

What are we monitoring when looking at CMP in pts. receiving PN

• Electrolytes: Na+, K+, Cl-, Ca2+, PO4, Mg+

• Glucose

• TGs

What serum proteins are we monitoring in patients receiving PN

• Pre-Albumin, Albumin, Transferrin, CRP

2 types of Parenteral Nutrition

1) Peripheral Parenteral Nutrition (PPN) = through peripheral IV

2) Total Parenteral Nutrition (TPN) = through central line

Peripheral Parenteral Nutrition (PPN)

a type of parenteral nutrition given through a peripheral IV

• used for mild to moderate malnutrition up to 1 week

• lesser osmolality than Total Parenteral Nutrition (TPN)

Total Parenteral Nutrition (TPN)

a type of parenteral nutrition given through a central line

• Central lines = subclavian- triple lumen cath

• PICC (perp. inserted central cath)

• Usually ordered with lipids

• use a micron filter with tubing

How often do parenteral bags and tubing need to be changed

q 24 hrs

A central-venous access device (CVAD) is associated with what risks?

Bloodstream infection, Pneumothorax, Hyperglycemia