Exam 3 - Enteral vs. Parenteral Nutrition

enteral - when is it given?

• the patient HAS a functioning GI tract, but something is preventing them from either not being able to swallow or have adequate caloric intake

reasons why people are given enteral nutrition

• intubation

• cancer

• stroke

• neuromuscular disorders

• burns

• sepsis

• aspiration pneumonia

nasal feeding tubes (long or short term? why?)

• SHORT TERM!!

  • due to DISCOMFORT and for body image issues

are nasal feeding tubes used for suction?

NOPE!!! only feedings

nasal feeding tubes - 2 names for what they are called in the hospital

1. dobhoff

2. corpak

nasal feeding tubes - in stroke patients, they are used in the meantime until they get what?

PEG TUBE!!

nasoduodenal tubes - completely bypass what? why would a patient get this?

• completely bypass the STOMACH

  • they would get this if they do NOT HAVE A STOMACH, or the patient has gastroparesis/delayed gastric emptying

nasoenteric tubes (nasoduodenal tubes) - short term or long term use?

• LONG TERM USE (bypass the upper gi tract)

nasoenteric tubes (nasoduodenal) - how is placement confirmed?

FLUOROSCOPY!! - an x-ray procedure that allows one to see the advancing NG tube, ensuring that it reaches its ultimate destination

what to do BEFORE starting feedings?

CHEST XRAY TO CONFIRM PLACEMENT!

how can you easily see that an NG tube is placed in the correct spot?

the tip of the NG tube is radiopague

why is NG tube placement SOOO IMPORTANT?

• one can accidentally insert it into the lungs (esp older adults who lost their gag reflex or have an altered level of consciousness)

4 NG tube placement techniques

• ensuring it is still at the proper length when you measured

• aspiration of contents (check pH!!)

• air auscultation (NOT USED IN PRACTICE)

• KUB/CXR

tools used to secure an NG tube? what does this do?

• tools - tape, safety pin, bridal

  • these make it harder for the tube to dislodge

how does air auscultation work IF IT WAS STILL USED IN PRACTICE?

• put stethoscope over stomach and blow air using your syringe and you’d hear the air

NG tube monitoring techniques

• check volume/patency

• ORAL AND NASAL HYGIENE!!

• residual checks (start slow, and the increase)

• keep patient at 30 degrees when feeding

NG tube - complications

• aspiration

• obstructed sinus drainage flow

• overfeeding

when checking the residual, what amount indicates that you should hold the feeding?

• 100-200 mL

PEG tube - short or long term? is it comfier than a dobhoff? easier to hide?

• LONG TERM!!

  • comfier and easier to hide!!!

PEG tubes - are they on CONTINUOUS or BOLUS feedings?

BOLUS feedings (get 250 mL of their tube feeding 4-5 times a day, as opposed to continuously being fed)

people with PEG tubes also need what?

WATER!!

people who receive feedings have WHO on consult?

NUTRITIONIST!!

what are cyclic feedings?

tube feeding is done continuously at night while the patient is sleeping

what is one thing to watch out for when you’re first starting out on tube feedings?

DIARRHEA, as it interferes with how the GI system normally digests

parenteral feedings - when are they given?

• for patients who do NOT have a functioning GI tract and enteral nutrition is not indicated

what conditions indicate someone to start TPN?

• conditions in which the GI tract is unable to absorb nutrition

  • bowel obstruction, short gut syndrome, post op ileus, gastric paresis

TPN - how is it administered? why?

PICC or CENTRAL LINE, due to VERY HIGH osmolality

TPN - nutrition facts

• high concentration of calories; up to 50% dextrose; lipids, protein, electrolytes, vitamins, and some elements

TPN - since it can go up to 50% dextrose, what nursing consideration should be taken?

• Q4 BLOOD SUGAR CHECKS!! (diabetic or not)

  • pancreas WILL get used to TPN (takes a day or 2)

    • EDUCATE patient on reasoning for Q4 blood sugar checks

TPN - how many days has one been NPO before being given TPN?

GREATER THAN 5 days (due to conditions that stop GI tract from functioning)

PPN - what is it? what’s different compared to TPN?

• PERIPHERAL parenteral nutrition

  • less hypertonic (dextrose less than 10%); SHORT TERM USE!!!

PPN - 1 risk associated with it

PHLEBITIS!!

TPN - nursing considerations/interventions

• tubing/solution MUST be changed EVERY 24 hrs regardless of how much is left

  • tubing MUST have a filter to catch dextrose/other crystallization and particles that can occur

• Q4/Q6 blood sugars (depending on hospital policy)

  • not diabetic? may require insulin until pancreas can adjust!!

• patient will STILL NEED IV FLUID REPLACEMENT!!!

• monitor daily electrolytes, glucose, and check for FVE due to the hyperosmotic fluid shifts in the blood

• assess lungs, daily weights, I&Os

TPN - how is it to be discontinued? what must you NEVER do? why?

• HOW to do it: SLOWLY decrease to discontinue

• NEVER abruptly stop TPN

  • can result in REBOUND HYPOGLYCEMIA

TPN - what do you do if “gramma pulls out her PICC line that was providing her TPN?”

run D10% at the same rate on peripheral line

TPN - do you need to hold it prior to surgery?

NOPE!

4 types of central access devices

1. triple lumen catheter

2. PICCs

3. tunneled central catheters (Hickman, Permacath)

4. Mediport

H pylori - when is it anticipated?

GASTRIC ULCERS!!

LFTs (AST/ALT/Alk phos) - when are they elevated?

• elevated in liver damage / hepatitis/cirrhosis

amylase/lipase - when are they elevated?

PANCREATITIS!!!