Electrolyte Imbalance and Dysphagia

Electrolyte Imbalance

• Three processes involved: Intake and absorption, disruption, and output.

Electrolyte Intake and Absorption

• Potassium (K+) is a key electrolyte with functions in skeletal, smooth, and cardiac muscle.
• Foods rich in potassium include fruits, potatoes, instant coffee, molasses, and Brazil nuts.
• Potassium absorption is easily achieved but can be disrupted by conditions like acidosis and alkalosis.

Dysphagia (Difficult Swallowing)

• Myogenic dysphagia can be caused by conditions like Myasthenia gravis, aging, muscular dystrophy, and polymyositis.
• Neurogenic dysphagia can be caused by conditions like stroke, cerebral palsy, Guillain-Barre Syndrome, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Diabetic Neuropathy, and Parkinson's Disease.
• Obstructive dysphagia can be caused by conditions like benign peptic stricture, lower esophageal ring, Candidiasis, head and neck cancer, inflammatory masses, and trauma/surgical restriction.
• Other causes include gastrointestinal or esophageal resection, rheumatological disorders, connective tissue disorders, and vagotomy.

Silent Aspiration

• A common occurrence in patients with neurological problems that leads to decreased sensation.

Diet Progression & Therapeutic Diets

• Clear Liquid Diet consists of broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices, and popsicles.
• Full Liquid Diet includes all clear liquids plus smooth textured dairy products.

Aspiration Precautions

• Positioning plays a critical role.
• Nurses are responsible for assessing patient risk for aspiration.
• Assistive personnel can be delegated the task of feeding but the nurse must supervise and direct care.

Aspiration Precautions Steps

• Identify patient using two identifiers.
• Review medical history, nutritional risks, and screening results to identify factors that could cause dysphagia.
• Assess current medications for medications that may impair swallowing and coughing reflexes.
• Assess patient for signs and symptoms of dysphagia, and refer to a speech-language pathologist (SLP) or registered dietitian (RD) if needed.
• Assess patient's health literacy to ensure they understand the information.
• Assess patient's mental status.
• Apply gloves.
• Provide verbal coaching to remind the patient to chew and swallow.
• Avoid mixing different textures in the same mouthful.
• Monitor swallowing and observe for respiratory difficulty.
• Minimize distractions and allow adequate time for chewing and swallowing.
• Use sauces and condiments to facilitate cohesive food bolus formation.
• Ask the patient to remain upright for at least 30-60 minutes after a meal.
• Provide thorough oral hygiene after meals.
• Ensure the patient is comfortable in an upright position.
• Perform hand hygiene.

Evaluation

• Observe the patient's ability to swallow food and fluids of various textures.
• Monitor pulse oximetry readings for high-risk patients during eating.
• Monitor intake and output, calorie count, and food intake.
• Weigh the patient daily or weekly.
• Observe the patient's oral cavity after meals.
• Use teach-back to ensure the patient and family caregiver understand the information.

Fluid Intake and Output

• Normal daily fluid intake is between 2200-2700mL
• Normal daily fluid output is between 2200-2700mL
• During prolonged heavy exercise, fluid intake can range between 300-1150mL/hour
• Prolonged heavy exercise can increase fluid output to 340-3120mL/hour
• Rehydration with sodium-containing fluids is necessary after prolonged vigorous exercise

Thirst

• Is a conscious desire for water
• Is an important regulator of fluid intake when plasma osmolality increases or blood volume decreases
• Fibroblast growth factor 23 (FGF-23) decreases renal excretion of phosphate
• Rising blood calcium levels decrease phosphate in blood, and vice versa

Factors Affecting Electrolyte Imbalance

• Diarrhea
• Endocrine Disorders
• Medications

Factors of Protein

• Blood clotting
• Fluid regulation
• Acid-base balance

Water

• Accounts for 60-70% of total body weight
• Lean people have a greater percentage of water
• Muscle contains more water than any other tissue except blood

Fluid Release

• Respiration
• Sweating
• Urine
• Stools
• Fever
• Vomiting
• Trauma (blood loss)
• Clinical Dehydration
• Medications

Digestion of Food

• Mechanical breakdown through chewing, churning, and mixing with fluid
• Chemical reactions reduce food to its simplest form

Enzymes

• Protein-like substances that speed up chemical reactions
• Essential for digestion

Factors that Affect Nutrition

• Environmental factors contribute to obesity
• 68.7% of Americans are overweight or obese
• Overweight: BMI 25 to 29
• Obese: BMI 30 or greater
• Cost of healthy food is increasing, making it difficult for some to afford
• Fewer safe places to walk and play
• Age: Older adults (65 and up) have a decreased need for energy due to slower metabolic rate
• Vitamin and mineral requirements remain unchanged with age

Intubation Procedure

• Rationale:
  • Increase patient cooperation and decrease anxiety
  • Provide a method for communication during intubation to alleviate stress and enhance cooperation
  • Preserve patient privacy
  • Ensure efficient procedure

Intubation Implementation

• Perform Hand Hygiene:
  • Reduces transmission of microorganisms
  • Allows easier manipulation of tube
• Positioning:
  • Place patient in upright high-Fowler position (unless contraindicated)
  • If comatose, raise head of bed as tolerated in semi-Fowler position with head tipped forward using a pillow chin to chest
  • If patient is forced to lie supine, place in reverse Trendelenburg position
  • Fowler position reduces risk of aspiration and promotes swallowing
  • Forward head position helps to close airway and allows for passage of tube into esophagus
• Vital Sign Monitoring:
  • Apply pulse oximeter/capnograph and monitor vital signs continuously
  • Provides baseline for objective assessment of respiratory status during and after tube insertion
  • Reduced oxygen saturation or increased end-tidal CO2 can indicate tube misplacement into the lungs or moving out of the stomach into lungs
• Clinical Judgment:
  • If there is an increase in end-tidal carbon dioxide or decrease in oxygen saturation, do not insert the tube until patient stability is determined
• Prepare Patient:
  • Place a bath towel over the patient's chest to prevent soiling of the gown
  • Keep facial tissues within reach for tearing that may happen during the procedure
• Mark Tube Length:
  • Determine the tube length to be inserted and mark the appropriate location with tape or indelible ink
  • Ensures organized procedure and estimation of length to be inserted
  • Option - Adult Method: Measure distance from tip of nose to earlobe to xyphoid process (NEX) of sternum, which approximates distance from nose to stomach. Mark this distance on the tube with tape.

Body Fluid Composition

• Adult males have 60% body weight as water, decreasing to 50% in older individuals.
• Body fluid is divided into two compartments: extracellular fluid (ECF) and intracellular fluid (ICF).
• ECF is found outside cells and further divided into intravascular fluid (liquid part of blood) and interstitial fluid (between cells).
• Transcellular fluid, secreted by epithelial cells, includes cerebrospinal fluid, pleural, peritoneal, and synovial fluids.

Body Fluid Electrolytes

• Body fluids contain ions, with positively charged ions called cations:
  • Sodium (Na+)
  • Potassium (K+)
  • Calcium (Ca+)
  • Magnesium (Mg2+)
• Negatively charged ions are called anions:
  • Chloride (Cl-)
  • Bicarbonate (HCO3-)
• Cations and anions combine to form salts.

Normal Lab Values

• Osmolality: 285-295 mOsm/kg
• Electrolytes:
  • Sodium (Na+): 136-145 mEq/L
  • Potassium (K+): 3.5-5.0 mEq/L
  • Chloride (Cl-): 98-106 mEq/L
  • Total CO2: 23-30 mEq/L
  • Bicarbonate (HCO3-): 21-28 mEq/L
  • Total Calcium (Ca2+): 9.0-10.5 mg/dL
  • Ionized Calcium (Ca2+): 4.5-5.6 mg/dL
  • Magnesium (Mg2+): 1.3-2.1 mEq/L
  • Phosphate: 3.0-4.5 mg/dL
  • Anion Gap: 6+/-4 mEq/L
• Arterial Blood Gases (ABG's):
  • pH: 7.35 to 7.45
  • PaCO2: 35 to 45 mmHg
  • PaO2: 80-100 mmHg
  • HCO3-: 21 to 28 mEq/L
  • O2 Saturation: 95% to 100%
  • Base Excess: -2 to +2 mmEq/L

Osmolality and Osmotic Pressure

• Osmolality: The number of particles per kg of water. Sodium (Na+) does not easily pass through the cell membrane
• Osmotic pressure: Force that pushes a fluid through a membrane

Acid-Base Balance

• The body maintains a neutral pH (7.35-7.45).
• Buffers, like bicarbonate (HCO3-), help regulate pH in extracelluar fluid aiding in regulating metabolic acid.
• Acid excretion:
  • Lungs: Responsible for respiratory/carbonic acid excretion.
  • Kidneys: Responsible for metabolic/non-carbonic acid excretion.

Acid-Base Imbalances

• Acidosis: A decrease in pH.
• Alkalosis: An increase in base (bicarbonate).
• Two types of acidosis:
  • Respiratory acidosis: Caused by impaired lung function.
  • Metabolic acidosis: Caused by kidney failure.
• Two types of alkalosis:
  • Respiratory alkalosis: Caused by hyperventilation.
  • Metabolic alkalosis: Caused by excessive loss of acid, particularly from vomiting.
• Both lungs and kidneys have compensatory mechanisms to help rebalance the acid-base balance.

Dysphagia (Difficulty Swallowing)

• Causes of dysphagia:
  • Myogenic (Muscle-related): Myasthenia gravis, aging, muscular dystrophy, polymyositis.
  • Neurogenic (Nerve-related): Stroke, cerebral palsy, Guillain-Barré syndrome, multiple sclerosis, amyotrophic lateral sclerosis, diabetic neuropathy, Parkinson's disease.
  • Obstructive (Physical blockage): Benign peptic stricture, lower esophageal ring, candidiasis, head and neck cancer, inflammatory masses, trauma/surgical restriction.
  • Other: Gastrointestinal or esophageal resection, rheumatological disorders, connective tissue disorders, vagotomy.

Dysphagia Signs and Monitoring

• Warning signs: Coughing during eating, change in voice tone, abnormal mouth or tongue movements, slow speech, abnormal gag reflex, delayed swallowing, food pocketing, regurgitation, pharyngeal pooling, delayed swallow trigger, inability to speak.
• Silent aspiration: Aspiration that occurs without obvious signs, common in neurological conditions.
• Monitor for signs of dysphagia, such as throat clearing, coughing, choking, gagging, and drooling. Suction airway as needed.

Nutritional Support

• Patients receiving standard IV fluids for more than 5-7 days are at high nutritional risk.
• Diet Progression & Therapeutic Diets:
  • Clear Liquid: Broth, bouillon, coffee, tea, clear juices, gelatin, fruit ices.
  • Full Liquid: Clear liquid plus dairy products, smooth textured foods.

Nasoenteric Tube Insertion and Removal

• Verify health care provider's order for tube type and feeding schedule, and check for prokinetic agent orders.
• Identify patient using two identifiers.
• Review patient's medical history (e.g., basilar skull fracture, nasal problems, anticoagulant therapy). This information may require a change of tube route.
• Assess patient's risk for developing a medical adhesive-related skin injury (MARSI), considering factors like age, dehydration, underlying conditions.
• Assess health literacy of patient or family caregiver.
• Determine patient's allergies, focusing on foods and adhesives.
• Explain the procedure to the patient and family caregiver. Teach-back to ensure understanding.
• Monitor the patient for signs of aspiration.

Swallowing and Feeding Techniques

• Use a chin-down maneuver, head-turn-plus-chin-down maneuver, and a small bite approach to help with swallowing.
• Provide verbal coaching, "Think about swallowing, Close your mouth, Cough to clear your airway" etc.
• Avoid mixing textures in the same mouthful and alternate liquids and bites of food.
• Minimize distractions during meals, allow time for chewing, and provide rest periods during meals.
• Use sauces and gravies to facilitate food bolus formation.

Metabolic Acidosis

• Metabolic acidosis is characterized by increased metabolic acids in the blood and decreased bicarbonate levels.
• Kidneys are unable to excrete these acids, leading to their accumulation in the blood.
• Common causes include diarrhea, where bicarbonate is directly removed from the body.
• Anion gap, a measure of the difference between positively and negatively charged ions in the blood, can be helpful in diagnosis.
• Decreased pH triggers chemoreceptors, leading to lung compensation through hyperventilation.

Respiratory Acidosis

• Respiratory acidosis occurs when excessive carbon dioxide (CO2) accumulates, leading to increased partial pressure of CO2 (PaCO2).
• This is often a result of hypoventilation, where breathing is insufficient.
• Kidneys compensate by increasing the excretion of acids in urine.

Risk Factors for Fluid, Electrolyte, or Acid-Base Imbalances

• Age
  • Young individuals may experience extracellular volume (ECV) deficits, osmolality imbalances, and clinical dehydration.
  • Older individuals can experience both ECV excess and deficit, as well as osmolality imbalances.
• Environment
  • Sodium-rich diets can lead to ECV excess.
  • Electrolyte-poor diets contribute to electrolyte deficits.
  • Hot weather can increase the risk of clinical dehydration.
• Gastrointestinal Output
  • Diarrhea, drainage, and vomiting can significantly impact fluid and electrolyte balance.
• Chronic Diseases
  • Cancer, COPD, cirrhosis, heart failure, oliguric renal disease can disrupt fluid and electrolyte balance.
• Trauma
  • Burns, crashes, head injuries, hemorrhage can lead to various imbalances.
• Therapies
  • Diuretics, IV therapy, and parenteral nutrition (PN) can influence fluid and electrolyte balance.

Fluid Imbalance

• Dehydration and ECV excess are common fluid imbalances.

Enteral Fluid Replacement

• Enteral fluid replacement involves providing fluids by mouth.
• Ice chips are considered half the volume. If a patient consumes 240 mL of ice chips, the actual intake is 120 mL.
• Contraindications for enteral fluid replacement include mechanical obstruction of the gastrointestinal tract, severe nausea, increased risk of aspiration, and impaired swallowing.

Parenteral Fluid Replacement

• Parenteral fluid replacement involves administering fluids through IV.
• Types include:
  • Parenteral Nutrition (PN)
  • Electrolyte therapy
  • Blood
  • Blood components

Types of IV Solutions

• Dextrose in Water
  • D5W: Dextrose 5% in water
  • D10W: Dextrose 10% in water
• Saline Chloride (NaCl) in Water Solution
  • 0.225% NaCl (1/4 Normal Saline)
  • 0.45% NaCl (1/2 Normal Saline)
  • 0.9% NaCl (Normal Saline)
  • 3-5% NaCl (Hypertonic Saline)
• Dextrose in Saline Solution
  • Dextrose 5% in 0.45% NaCl (1/2 Normal Saline)
  • Dextrose 5% in 0.9% NaCl (D5NS)
• Multiple Electrolyte Solutions
  • Lactated Ringers (LR)
  • Dextrose 5% (LR, D5LR)

Nutrition Key Terms

• Albumin: A plasma protein essential for maintaining blood volume and pressure.
• Anorexia Nervosa: An eating disorder characterized by extreme weight loss, distorted body image, and fear of gaining weight.
• Basal Metabolic Rate (BMR): The minimum amount of energy required to sustain life at rest.
• Body Mass Index (BMI): A measure of body fat based on height and weight.
• Bulimia Nervosa: An eating disorder characterized by binge eating followed by purging behaviors.
• Carbohydrates: Organic compounds composed of carbon, hydrogen, and oxygen, serving as the primary energy source for the body.
• Catabolism: The breakdown of complex molecules into simpler ones, releasing energy.
• Daily Values: Recommended dietary intake based on daily nutrient needs.
• Dietary Reference Intakes (DRIs): A set of nutrient recommendations for healthy individuals.
• Dispensable Amino Acids: Amino acids that the body can synthesize from other sources.
• Dysphagia: Difficulty swallowing.
• Enteral Nutrition (EN): Providing nutritional support through the gastrointestinal tract by tube feeding or oral supplements.
• Fat-soluble Vitamins: Vitamins that dissolve in fat and are stored in the body (e.g., vitamins A, D, E, K).
• Fiber: Indigestible plant material that aids digestion and promotes bowel regularity.
• Food Security: Access to safe, nutritious food in sufficient quantities to meet dietary needs and preferences.
• Hypervitaminosis: Toxicity due to excessive intake of vitamins.
• Ideal Body Weight (IBW): A healthy weight range based on height and sex.
• Indispensable Amino Acids: Essential amino acids that the body cannot synthesize and must be obtained from the diet.
• Insulin: A hormone that regulates blood glucose levels.
• Intravenous: Administration of fluids or medications directly into a vein.
• Ketones: Energy-producing byproducts of fat metabolism.
• Kilocalories: Units of energy defined as the amount of heat required to raise the temperature of 1 kg of water by 1 degree Celsius.
• Lipids: Fats and oils that are essential components of cell membranes and serve as energy reserves.
• Macrominerals: Minerals required in relatively large amounts (e.g., calcium, phosphorus, magnesium, sodium, potassium, chloride).
• Malabsorption: Impaired absorption of nutrients from the gastrointestinal tract.
• Malnutrition: A nutritional deficiency caused by inadequate intake, absorption, or utilization of nutrients.
• Medical Nutrition Therapy (MNT): Nutritional counseling and treatment by a registered dietitian.
• Metabolism: All chemical processes occurring within the body, including the breakdown and synthesis of molecules.
• Minerals: Inorganic substances that are essential for various bodily functions.
• Nitrogen Balance: The balance between nitrogen intake and output, reflecting protein metabolism.
• Parenteral Nutrition (PN): Providing nutritional support directly into the bloodstream, bypassing the gastrointestinal tract.
• Peristalsis: Wave-like muscle contractions that propel food through the digestive tract.
• Resting Energy Expenditure (REE): The energy needed to sustain life at rest, excluding the energy used for physical activity.
• Simple Carbohydrates: Sugars that are easily and quickly absorbed by the body.
• Trace Elements: Minerals required in very small amounts (e.g., iron, zinc, copper, iodine).
• Triglycerides: The main type of fat found in the body and food.
• Vitamins: Organic compounds required in small amounts for various bodily functions.
• Water-soluble Vitamins: Vitamins that dissolve in water and are not stored in the body (e.g., vitamin C, B vitamins).
• Villi: Small, finger-like projections in the small intestine that increase surface area for nutrient absorption.

Biochemical Units of Nutrition

• The body requires fuel for cellular metabolism, repair, organ function, growth, and movement.

Factors Affecting Energy Requirements

• Age
• Body Mass
• Gender
• Fever
• Starvation
• Menstruation
• Illness
• Injury
• Infection
• Activity
• Level of Thyroid Function

Factors Affecting Metabolism

• Illness
• Pregnancy
• Lactation
• Activity Level

Proteins

• Provide energy at 4kcal/g.
• Essential for growth, maintenance, and repair of body tissues.
• Components of collagen, hormones, enzymes, immune cells, DNA, and RNA.

Weight

• Daily weight measurements should be taken at the same time each day, using the same scale and comparable clothing.
• Significant weight loss or gain (3 or more pounds in 24 hours) should prompt assessment for fluid retention or dehydration.

Body Mass Index (BMI)

• Calculate BMI by dividing weight in kilograms by height in meters squared.
• (i.e., 180 lbs / 2.2 / 5.6 or 1.67 m² = 29.34)
• A BMI of 29.34 indicates overweight and nearing obesity.

Laboratory and Biochemical Tests

• Used to diagnose malnutrition, fluid balance, liver function, kidney function, and the presence of disease.

Dysphagia (Difficult Swallowing) Causes

• Myogenic
  • Myasthenia gravis
  • Aging
  • Muscular dystrophy
  • Polymyositis
• Neurogenic
  • Stroke
  • Cerebral palsy
  • Guillain-Barré Syndrome
  • Multiple sclerosis
  • Amyotrophic lateral sclerosis
  • Diabetic neuropathy
  • Parkinson's disease
• Obstructive
  • Benign peptic stricture
  • Lower esophageal ring
  • Candidiasis
  • Head and neck cancer
  • Inflammatory masses
  • Trauma/surgical restriction
• Other
  • Gastrointestinal or esophageal resection
  • Rheumatological disorders
  • Connective tissue disorders
  • Vagotomy

Silent Aspiration

• Silent aspiration is a particular risk for neurological patients, as it occurs without the typical signs of aspiration.
• It can lead to decreased sensation and increased vulnerability.

Diet Progression & Therapeutic Diets

• Clear Liquid: Broth, bouillon, coffee, tea, clear fruit juices, gelatin, fruit ices, popsicles.
• Full Liquid: Includes all clear liquid items plus smooth dairy products.

Enteral Tube Insertion - Assessment Considerations

• Allergies: Communication of patient allergies ensures safety.
• Medical Adhesive: If used to anchor the enteral tube to the nose, monitor for medical device-related pressure injury (MDRPI).
• Height and Weight: Provides baseline data for nutritional improvement.
• Hydration, Electrolytes, and Caloric Needs: Assessment of hydration status, electrolyte balance, and caloric needs is crucial.
• Intake and Output (I&O): Monitoring I&O is essential for fluid balance.
• Nasal Examination: Inspect each nostril for patency, irritation, skin breakdown, and signs of previous NG tube placement (MDRPI).
• Abdominal Assessment: Check for bowel sounds, pain, tenderness, or distention, as these may indicate medical problems.
• Mental Status: Evaluate the patient's ability to cooperate, sedation level, and any potential cognitive impairment.
• Cough and Gag Reflex: Determine the presence and effectiveness of these protective mechanisms.
• Swallowing Ability: Evaluate the patient's ability to swallow safely.
• Artificial Airway: Assess for the presence of an artificial airway, as it can complicate tube placement.
• Patient Knowledge and Experience: Assess the patient's understanding, prior experience, and feelings about the procedure.
• Patient Goals and Preferences: Individualize care by considering the patient's preferences.

Enteral Tube Insertion - Planning Considerations

• Explanation of Procedure: Describe the procedure and the sensations the patient may experience.
• Communication During Intubation: Explain how the patient can communicate during the insertion (e.g., raising a finger to indicate discomfort).
• Privacy: Ensure patient privacy by closing the door and bedside curtain.
• Equipment Preparation: Obtain and organize necessary equipment for the procedure at the bedside.

Enteral Tube Insertion - Implementation Considerations

• Hand Hygiene: Perform thorough hand hygiene.
• Positioning: Position the patient upright in high-Fowler's position (unless contraindicated).
• Fowler's Position: Fowler's position reduces aspiration risk and promotes effective swallowing.
• Pulse Oximetry/Capnography: Apply and monitor pulse oximetry or capnography continuously.
• Safety Precautions: Do not insert the tube if there is a decrease in oxygen saturation or an increase in end-tidal carbon dioxide until patient stability is assessed.
• Protection: Place a towel over the patient's chest to prevent soiling of their gown.
• Tube Length Determination and Marking: Determine the appropriate length of the tube and mark it with tape or indelible ink.
• NEX Measurement: Measure the distance from the tip of the nose to the earlobe to the xyphoid process (NEX) of the sternum. Mark this length on the tube.

Enteral Tube Insertion - Clinical Judgment

• Alternative Techniques: If blind placement poses an unacceptable risk, use techniques such as CO2 sensors or electromagnetic tracking devices, or consider visualization or imaging techniques for tube placement by trained clinicians.

Metabolic Acidosis

• Increased metabolic acids or decreased base bicarbonate in the blood causing decreased pH.
• Kidneys fail to excrete metabolic acids, leading to their accumulation in the blood.
• Bicarbonate can be removed directly from the body through diarrhea.
• Decreased pH triggers chemoreceptors, which cause hyperventilation to compensate.

Respiratory Acidosis

• Increased CO2 and PaCO2 levels due to hypoventilation.
• Kidneys compensate by excreting metabolic acids in the urine.

Risk Factors for Fluid, Electrolyte, and Acid Alterations

• Age:
  • Infants are susceptible to fluid and electrolyte imbalances due to their lower body weight and immature kidney function.
  • Older adults are prone to imbalances due to declining kidney function and changes in fluid needs.
• Environmental Factors:
  • Sodium-rich diets can lead to fluid excess.
  • Electrolyte-poor diets can result in electrolyte deficits.
  • Hot weather can lead to dehydration.
• Gastrointestinal Output:
  • Diarrhea, drainage, vomiting, and excessive sweating can deplete fluids and electrolytes.
• Chronic Diseases:
  • Conditions like cancer, COPD, cirrhosis, heart failure, and chronic kidney disease can disrupt fluid and electrolyte balance.
• Trauma:
  • Burns, crash injuries, head injuries, hemorrhage, and other trauma can cause fluid loss and electrolyte shifts.
• Therapies:
  • Diuretics can lead to fluid and electrolyte loss.
  • Intravenous therapy and parenteral nutrition can alter fluid balance.

Fluid Imbalance - Nursing Diagnoses

• Fluid Imbalance
• Dehydration
• Acid Base Imbalance
• Lack of knowledge of fluid regimen

Enteral Fluid Replacement

• Ice chips are equivalent to half the volume of liquid.

Protein Factors: Key Functions

• Blood Clotting
• Fluid Regulation
• Acid-Base Balance

Water

• Essential for all cell function
• Accounts for 60% to 70% of total body weight.
• Lean individuals have a higher percentage of body water due to the water content of muscle.

Fluid Release

• Respiration
• Sweating
• Urine
• Stools
• Fever
• Vomiting
• Trauma (Blood loss)
• Clinical Dehydration
• Medications

Digestion of Food

• Mechanical breakdown involves chewing, churning, and mixing with fluids.
• Chemical reactions break down food into its simplest forms.

Enzymes

• Protein-like substances that catalyze chemical reactions.
• Critical for digestion.

Factors Affecting Nutrition

• Environmental Factors:
  • Obesity is a growing concern, with 68.7% of Americans being overweight or obese.
  • Overweight is defined as a BMI of 25 to 29.
  • Obesity is defined as a BMI of 30 or greater.
  • Access to affordable, healthy food and safe physical environments are crucial determinants of dietary choices.
• Age:
  • Older adults (65+) have a decreased energy requirement due to a slower metabolic rate.
  • However, their vitamin and mineral needs remain the same.

Indications for Parenteral Nutrition (PN)

• Nonfunctioning Gastrointestinal Tract:
  • Massive small bowel resection
  • Gastrointestinal surgery
  • Gastrointestinal bleeding
  • Paralytic ileus
  • Intestinal obstruction
  • Trauma to the abdomen, head, or neck
  • Severe malabsorption
  • Intolerance to enteral feeding
  • Chemotherapy, radiation, and bone marrow transplants

PN Complications

• Tension pneumothorax is a potential complication associated with tube insertion and may occur up to 24 hours after placement.

Transitioning from PN/EN Feeding

• Patients can transition from PN/EN feeding when they achieve 1/3 to 1/2 of their daily caloric intake per day via enteral feeding.

Impaired or Low Nutritional Intake Assessment: Key Findings

• Changes in Weight:
  • Significant weight loss, especially more than 20% below ideal body weight
• Body Mass Index (BMI):
  • Value below 18.5 indicates underweight.
• 24-Hour Food and Fluid History:
  • Inadequate caloric intake
  • Limited fluid intake
• Physical Assessment:
  • Poor muscle tone
  • Fatigue
  • Hair loss
  • Dry, scaly skin
  • Pale conjunctiva and mucous membranes
• Medication History:
  • Medications that can affect appetite or nutrient absorption.
• Social History:
  • Factors affecting the individual's ability to cook or access food.

Medical Nutrition Therapy (MNT)

• The use of specific nutritional therapies to manage illnesses, injuries, or conditions.
• MNT is essential for safe and effective patient care.

Enteral Tube Insertion: Essential Considerations

• Communication of patient allergies is crucial to avoid adverse reactions.
• Secure enteral tube placement to prevent accidental removal.
• Assessment Activities
  • Height, weight, hydration status, electrolyte balance, caloric needs, and intake and output (I&O)
    • Provides baseline data to monitor nutritional progress.
  • Assess patency of nostrils, skin integrity, and any signs of medical device-related pressure injury (MDRPI).
    • Ensures proper tube placement and minimizes risks of complications.
  • Conduct a physical assessment of the abdomen (see Chapter 30).
    • Identifies potential contraindications to enteral feedings.
  • Assess mental status, gag reflex, swallowing ability, presence of critical illness, and artificial airway status.
    • Identifies potential complications like accidental tube placement in the lungs.
  • Assess patient knowledge, experience with tube insertion, and feelings about the procedure.
    • Provides appropriate patient education and support.
  • Determine patient goals and preferences for the procedure.
    • Personalizes care to meet individual needs.
• Planning
  • Explain the procedure to the patient and describe sensations they may experience.
    • Reduces anxiety and increases cooperation.
  • Instruct the patient on how to communicate during the procedure (e.g., raising index finger to signal gagging or discomfort).
    • Allows the patient to express discomfort during the procedure.
  • Ensure privacy during the procedure.
  • Gather necessary equipment for tube insertion.
    • Ensures a smooth and organized procedure.
• Implementation
  • Perform hand hygiene and position the patient upright in a high-Fowler's position (unless contraindicated).
    • Reduces risk of aspiration and promotes effective swallowing.
  • If the patient is comatose, raise the head of the bed as tolerated in a semi-Fowler's position with the head tipped forward.
    • Helps with airway closure and passage of the tube into the esophagus.
  • Monitor vital signs, including pulse oximetry or capnography.
    • Provides baseline respiratory status monitoring.
  • Place a bath towel over the patient's chest and have facial tissues readily available.
    • Protects the gown from soiling and assists in managing excessive secretions.
  • Measure tube length using the nose-earlobe-xyphoid process (NEX) method and mark it on the tube.
    • Ensures the correct tube length for placement.
  • Monitor patient closely during and after tube insertion for any signs of respiratory distress, including decreased oxygen saturation or increased end-tidal carbon dioxide levels.
    • Indicates potential complications like tube malpositioning or aspiration.
• Clinical Judgment:
  • Be cautious about blind tube placement, especially in high-risk patients.
  • Consider using visualization or imaging techniques when performing tube insertions.
  • Use devices designed to detect pulmonary intubation (e.g., capnography) to enhance patient safety.

This quiz explores the processes involved in electrolyte imbalance, focusing on potassium's role in muscle function and the factors affecting its absorption. Additionally, it covers different types of dysphagia, including myogenic, neurogenic, and obstructive causes, along with their associated conditions.