Enteral & Parenteral Nutrition, IV Therapy, and Vital Signs

Scope of Practice & Legal Responsibilities

  • Nutritional support and IV therapy are nursing responsibilities; CNAs/techs never:

    • Insert feeding tubes (NG, naso-enteral, G-tubes, J-tubes, PEG, etc.)

    • Check placement or measure residual volumes

    • Insert, start, regulate, or discontinue peripheral/central IVs or TPN lines

    • Adjust infusion pumps, clamps, or flow rates

  • CNAs do:

    • Monitor, record, and report observations

    • Provide comfort, hygiene, positioning, and line/tube protection

    • Notify the nurse immediately about alarms, abnormal findings, or patient distress

Enteral Nutrition (Tube Feeding)

  • Definition: Delivery of nutrients directly into the GI tract through a tube (process = gavage)

  • Indications: Inability/unwillingness to ingest food (coma, dysphagia, throat trauma, eating disorders, AIDS, cancer, etc.)

  • Formulas: Doctor-ordered; contain proteins, carbs, fats, vitamins, minerals

    • Unopened → room temp storage

    • Opened → refrigerate; discard after 24 h

    • Warm to room temp (≈ 30 min sit-out); never microwave or stove-heat

  • Tube Types & Time Frames

    • NG (nasogastric) – nose → stomach; short-term (≤ 6 wk)

    • Naso-enteral (ND/NJ) – nose → small intestine; short-term

    • Gastrostomy (G-tube) – surgical stoma → stomach; long-term (> 6 wk)

    • Jejunostomy (J-tube) – stoma → jejunum; long-term

    • PEG (Percutaneous Endoscopic Gastrostomy) – endoscope guided, small skin incision → stomach; long-term

  • Feeding Methods

    • Syringe/bolus: formula poured into syringe attached to tube

    • Gravity drip: bag hung above pt., flow controlled via roller clamp

    • Pump (continuous): program ml/hr; alarms for occlusion, empty bag, etc.

  • Schedules

    • Intermittent (scheduled) → 3-8 feeds/day, 8–12 oz8–12\ \text{oz} over ≤ 30 min

    • Continuous → 24 h via pump; nurse checks placement q4h

  • Aspiration Prevention

    • Verify tube placement (nurse)

    • High-Fowler’s (≥ 45°) during and 1-2 h post-feed; avoid left side-lying afterwards

    • Feed slowly; monitor residuals (nurse task)

  • Monitor & Report

    • GI: nausea, vomiting, distention, residual high, diarrhea, constipation, delayed emptying

    • Respiratory: cough, ↑RR, wheeze → possible aspiration

    • Stoma/nostril: redness, swelling, drainage, odor, pain, skin breakdown

    • Pump alarms, leaking, air entry, tube displacement

  • Comfort & Hygiene

    • Most pts. NPO; perform oral care q2 h while awake, lubricate lips, offer ice chips per RN

    • Clean nose/nostrils q4-8 h, secure tube to nose and garment (rubber band, clip) to prevent tugging

Parenteral Nutrition (TPN / Hyperalimentation)

  • Nutrient solution infused directly into bloodstream via central venous catheter

  • Contains water, dextrose, amino acids, lipids, electrolytes, vitamins, minerals

  • Indications: Non-functional GI tract, prolonged NPO ≥ 5–7 d, severe anorexia, coma, GI surgery/injury

  • Risks: Infection (sepsis), fluid overload, electrolyte or glucose imbalance

  • CNA Role: Observe & report fever, chills, chest pain, dyspnea, thirst, tachy/irregular pulse, diaphoresis, confusion; provide oral care & general hygiene

IV Therapy Basics

  • Definition: Fluids, meds, or blood products delivered via needle/catheter into vein

  • Sites

    • Peripheral: hand, wrist, forearm (adults); foot generally avoided in toddlers

    • Central: catheter tip near/right-atrium

    • Central venous catheter (CVC), tunneled catheter, implanted port

    • PICC (Peripherally Inserted Central Catheter) – enters arm vein, terminates in superior vena cava

  • Equipment

    • Solution bag, drip chamber, tubing, roller clamp, IV pole/pump

    • Flow rate units: gtt!/!min\text{gtt}!/!\text{min} or mL!/!h\text{mL}!/!\text{h}; gtt=drops\text{gtt} = \text{drops}

  • Safety

    • Ensure tubing unkinked, no dependent loops, bag above heart level, site dry/intact

    • Move IV pole to side pt. turns; provide slack during repositioning

  • Report Immediately

    • Pump alarm, no drip/too fast, bag nearly empty

    • Local: redness, swelling, warmth, pain, blood back-up

    • Systemic: fever, cyanosis, SOB, chest pain, LOC changes

Vital Signs Overview

Vital signs reflect temperature, pulse, respiration, blood pressure (TPR-BP). Many agencies also include SpO₂ & pain.

Temperature

  • Normal Ranges

    • Oral: 97.6–99.6∘!F97.6–99.6^{\circ}!F ( 36.5–37.5∘!C36.5–37.5^{\circ}!C )

    • Rectal: 98.6–100.6∘!F98.6–100.6^{\circ}!F

    • Axillary: 96.6–98.6∘!F96.6–98.6^{\circ}!F (least reliable)

    • Tympanic: ≈98.6∘!F\approx 98.6^{\circ}!F

    • Temporal artery: ≈99.6∘!F\approx 99.6^{\circ}!F

  • Contra-indications

    • Oral: <5 yr, unconscious, mouth surgery/trauma, O₂ therapy, mouth-breather, NG tube, seizure risk

    • Rectal: diarrhea, rectal surgery/disorder, heart disease (stimulates vagus nerve), combative/confused

    • Tympanic: ear infection, drainage, excess cerumen

    • Axillary: avoid immediately post-bath

  • Devices & Color Codes

    • Electronic/digital (probe covers), tympanic, temporal scanner, disposable chemical dot, glass (mercury)

    • Glass stems: red = rectal, blue = oral/axillary; shake down before use

  • Procedures (key points)

    • Oral: probe sublingual at base/side; lips closed, wait for beep

    • Rectal: Sims’ position, lubricate, insert ½ inch (electronic) / 1 inch (glass); hold in place

    • Axillary: dry axilla, probe center, arm across chest

    • Tympanic: adult—pull ear up & back; child <4 yr—down & back

    • Temporal: sweep mid-forehead to hairline on exposed side only

  • Terminology: febrile/febrile (with fever), afebrile (without)

Pulse

  • Sites: radial (routine), carotid (CPR), apical (stethoscope, tip of heart), brachial, femoral, popliteal, posterior tibial, dorsalis pedis

  • Normal Adult Range: 60–100 beats⋅min−160–100\ \text{beats·min}^{-1}

    • Tachycardia: >100

    • Bradycardia: <60

  • Characteristics

    • Rhythm: regular vs. irregular

    • Force: bounding, strong, weak, thready

  • Apical–Radial: two staff measure simultaneously; difference = pulse deficit

  • Counting: always full 60 s for accuracy, especially if irregular

Respiration

  • One inspiration + one expiration = 1 breath

  • Normal Adult Range: 12–20 breaths⋅min−112–20\ \text{breaths·min}^{-1}

  • Observe rate, depth (shallow/deep), rhythm, symmetry, effort (labored/unlabored), sounds (wheezes, gurgles)

  • Count unobtrusively immediately after pulse while pt. unaware

Blood Pressure

  • Physiology: BP=SystolicDiastolicBP = \dfrac{\text{Systolic}}{\text{Diastolic}}

    • Systolic = ventricular contraction (working phase)

    • Diastolic = ventricular relaxation (resting phase)

  • Normal Range (Adult): 90–120/60–80 mmHg90–120/60–80\ \text{mmHg}

    • Hypertension: ≥140/≥90\ge 140/\ge 90

    • Hypotension: systolic <90 or symptomatic drop (postural)

  • Influencing Factors: age ↑, weight ↑, pain, stress, smoking, race (↑ risk in African-Americans), meds, position (supine > sitting > standing)

  • Equipment

    • Aneroid sphygmomanometer + stethoscope (Korotkoff sounds)

    • Electronic/wrist monitors (no stethoscope)

  • Cuff Placement Rules

    • Bare upper arm, mid-arm at heart level, bladder encircles 80% of arm

    • Avoid arm with IV, dialysis shunt, cast, injury, or same side as mastectomy

  • Procedure (manual)

    1. Let pt. rest 10-20 min

    2. Place cuff snug; locate brachial artery

    3. Inflate 20–30 mmHg20–30\ \text{mmHg} above last known systolic

    4. Deflate 2–3 mmHg/sec; first sound = systolic, disappearance = diastolic

Pulse Oximetry (SpO₂)

  • Measures % hemoglobin saturated with O₂

  • Normal: 95–100%95–100\% (agency parameters vary)

  • Probe sites: finger, toe, earlobe, nose, forehead

  • Remove nail polish/artificial nails; secure probe; report alarms or SpO₂ below ordered limit

Pain (5th or 6th Vital Sign)

  • Subjective; use 0–10 scale, faces, FLACC, etc.

  • Assess location, onset, duration, characteristics, alleviating/aggravating factors, impact on function

  • Report new/worsening pain promptly; follow RN instructions for non-pharm comfort measures

CNA Reporting Guidelines

Immediately inform the nurse when you observe:

  • Any vital sign outside ordered/normal range or drastically different from prior reading

  • Feed-related complications: aspiration signs, high residual (as told), diarrhea, vomiting, tube displacement, pump alarms

  • IV/TPN issues: alarms, infiltration, phlebitis, systemic symptoms

  • Equipment malfunctions you cannot correct within your scope

Quick Reference Matrix (Adult Normals)

  • Oral Temp: 98.6∘!F98.6^{\circ}!F

  • Pulse: 60–100 bpm60–100\ \text{bpm}

  • Resp: 12–20 rpm12–20\ \text{rpm}

  • BP: 90–120/60–80 mmHg90–120/60–80\ \text{mmHg}

  • SpO₂: 95–100%95–100\% (unless otherwise ordered)

These consolidated notes encapsulate all major and minor points, procedures, precautions, numerical values, and scope-of-practice boundaries presented in the lecture transcript.