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Enteral Nutrition (Tube Feeding) (double lumen) -​ Alternative feeding method to ensure a. Large tube- drains gastric content adequate nutrition through the b. Small tube - allows for an inflow of atmospheric gastrointestinal syst...

Enteral Nutrition (Tube Feeding) (double lumen) -​ Alternative feeding method to ensure a. Large tube- drains gastric content adequate nutrition through the b. Small tube - allows for an inflow of atmospheric gastrointestinal system. air, which prevents a vacuum if the gastric tubes -​ Means of nasogastric or nasointestinal adheres to the wall tube, gastrostomy or jejunostomy. stomach Indication: -​ Anorexia -​ Severe Protein-energy undernutrition -​ Coma -​ Liver failure -​ Head or neck trauma -​ Critical illnesses e.g. burns causing metabolic stress Contraindications: -​ Intestinal Obstruction -​ Paralytic ileus -​ Intractable vomiting -​ Diarrhea Gl hemorrhage NGT (Nasogastric Tube) NGT is a flexible plastic tube inserted through the nostrils, down the nasopharynx, and into the stomach or the upper portion of the small intestine. Placement of NGT is always confirmed with an X-ray prior to use (Perry Potter & Ostendorf 2014) An NGT use for feeding should be labelled. The tube is used to feed patients who may have swallowing difficulties (dysphagia) or require additional nutritional supplements. Can also remove gastric content, either draining the stomach by gravity or by being connected to a suction pump, the NGT is used to prevent nausea, Manifestation of Client at Risk for Aspiration vomiting, gastric distention, or to wash the stomach from toxins. 1. Decreased level of consciousness 2. Poor cough or gag reflex Insertion of NGT is an invasive procedure 3. Endotracheal intubation 4. Recent extubation Types of NGT (Nasogastric Tube) 5.Inability to cooperate with the 1. Levin tube procedure a flexible rubber or plastic, single lumen tube with 6. Restlessness or agitation holes near the tip. 2. Salem pump tube Nursing Alert: Administering medication through -​ Document all relevant information enteric feeding may adversely affect the absorption. -​ Absence of nausea and vomiting when should be avoided if possible. to avoid nutrient and tubes removed drug interaction medication should not be mixed with the feeding formulas. Percutaneous Endoscopic Gastrostomy (PEG) Safety Considerations: PEG or PEJ -​ Perform hand hygiene. -​ is a surgical procedure for placing a -​ Check the room for additional precautions. feeding tube without having to perform an -​ Introduce yourself to the patient. open operation on the abdomen. -​ Confirm patient lD using two patient -​ A gastrostomy (a surgical opening into the identities (e.g name & date of birth) stomach) is performed percutaneously -​ Explain the process to patients, offer using an endoscope to determine where to analgesia, bathroom, etc. place the feeding tube in the stomach and -​ Listen and attend to patient cues. secure it in place. -​ Ensure patient's privacy and dignity. -​ Assess ABCCS/suction/oxygen/safety Purpose -​ Ápply principles of asepsis and safety. -​ To feed those who cannot swallow -​ Check vital signs. -​ To provide fluids and nutrition directly into -​ Complete necessary focused assessment. the stomach -​ Check patency of nares and intactness of nasal tissues. Check for history of nasal Who does PEG? surgery or deviated septum -​ A general surgeon -​ Determine presence of gag reflex -​ An otolaryngologist (ENT specialist) -​ Assess mental status or ability to -​ A gastroenterologist (Gl specialist) cooperate with procedure -​ Before inserting an NGT, determine the Indications size of tube to be inserted. -​ Those in which normal or nutrition feeding is impossible -​ Neurological disorders of swallowing Removing of Nasogastric Tube -​ Anatomical (e.g. cleft lip and palate during Materials to be Prepared: the process of correction) -​ Disposable pad -​ Cognitive impairment and depressed -​ Tissues consciousness (e.g. head injury) -​ Clean gloves -​ Mechanical obstruction to swallowing -​ Emesis basin -​ To decompress the stomach contents -​ Mouthwash as prescribed -​ Referred as a "venting PEG" -​ 50ml syringe a.​ is placed to prevent and manage -​ Plastic disposable bag nausea and vomiting e.g. patient with a malignant bowel -​ Assess presence of bowel sounds obstruction -​ Assess absence of nausea and vomiting -​ Used to treat volvulus of the stomach when tube is clamped -​ Confirm the physician's order to remove Contraindication the tube -​ Ascites -​ Peritonitis Removal Nasogastric Tube -​ Portal hypertension -​ Perform handwashing -​ Peritoneal dialysis -​ Ask for Patients name -​ Large hiatal hernia -​ Provide privacy -​ Hepatomegaly -​ Assist the client to sitting position if health -​ Short life span permits -​ Abdominal wall infection -​ Detached the tube -​ Abdominal burns -​ Remove the NGT -​ High aspiration risk -​ Ensure clients comfort: -​ Atypical abdominal anatomy a.​ Provide mouth care b.​ Assist the client to blow the nose Advantages: -​ Dispose the equipment -​ less time -​ Assess the NGT drainage it suction was -​ less risk used  -​ costs less than a classic surgical gastrostomy Mechanical complication -​ Clotted catheter Types of Gastrostomy Tube -​ Venous thrombosis -​ Gastrostomy Tube Balloon Tipped -​ Air embolism -​ Low Profile Gastrostomy Tube Mushroom -​ Precipitation Shape Septic complication Benefits of PEG feeding -​ Fever -​ Well tolerated -​ Hematogenous seeding -​ Improved nutritional status -​ Contaminated fluids -​ Ease of usage over other methods -​ Central line site – erythema, tenderness, -​ Satisfactory use by home carers or purulent drainage -​ Low incidence of complications -​ Common organism – staph epidermidis -​ Reduction in aspiration pneumonia /aureus associated with swallowing disorders -​ Diagnosis – blood culture -​ Cost effective relative to alternative methods particularly when reasonably long TPN – nursing process survival expected. Planning: -​ Provide adequate calories and nutrition Total Parenteral Nutrition -​ Provide contamination-free mode of Access: delivering TPN solution -​ Subclavian veins -​ Discontinue infusion maintaining sterile -​ Internal jugular veins technique -​ Femoral veins -​ Brachial veins Intervention: -​ Administering TPN Catheter type -​ Discontinuing infusion GOLDEN RULES FOR ADMINISTERING DRUGS SAFELY 1.​ Administer the right drug 2.​ Administer the right drug to the right patient 3.​ Administer the right dose 4.​ Administer the right drug by the right route 5.​ Administer the right drug at the right time 6.​ Document each drug you administer Total Parenteral Nutrition 7.​ Teach your patient about the drugs he is receiving Site Insertion 8.​ Take a complete drug history -​ Informed consent 9.​ Find out if the patient has any drug -​ Pre-op preparation allergies -​ Patient preparation 10.​ Be aware of potential drug-drug or -​ Patient positioning drug-food interactions -​ Skin preparation -​ Equipment/procedure preparation Preparing the equipment: -​ Catheter stabilization -​ TPN solution(check for clouding, floating -​ documentation debris or a change in color) -​ Pump Insertion complication -​ Administration set with a filter -​ Pneumothorax -​ Alcohol swabs/gloves -​ Hemothorax -​ IV pole -​ Laceration of vessel -​ Wash hands before preparing the solution -​ Injury to brachial plexus for administration and in a clean area -​ Injury to thoracic duct -​ Air / catheter embolism Reducing the risk of infection: -​ Catheter misplacement -​ Maintain STRICT aseptic technique when -​ Cardiac handling the equipment used to administer therapy  -​ TPN solution serves as a medium for -​ Change tubing and filter every 24 hours bacterial growth and a central venous line using strict aseptic technique. Secure all provides systemic access junctions -​ Perform IV site care and dressing changes Prevention of sepsis: according to hospital protocol -​ Handwashing -​ Check the infusion pump’s volume meter -​ Insertion technique – aseptic technique and time to monitor for irregular flow rate. -​ Skin cleansing at site insertion Gravity should never be used to administer -​ Using least number of hubs or lumens TPN -​ Keeping dressing dry, occlusive and -​ Record client's vital signs when you initiate drainage free and every 4 hours thereafter. Be alert for -​ Changing lines over wire using sterile increased body temp technique -​ Monitor glucose level as ordered -​ Changing pulmonary artery catheters -​ Accurately record I & O every 5 days -​ Assess physical status daily – weight etc -​ Use central venous catheters only when -​ Monitor lab results – s/s of nutritional necessary aberrations -​ Not accessing TPN frequently -​ Provide emotional support, oral care -​ Document all assessment findings and ADMINISTRATION (delivery) nursing interventions Continuously: -​ the infusion is given over a 24-hour period Pediatric clients: -​ begin at a slow rate and increases to the -​ TPN Maintains nutritional status & fuels optimal rate growth -​ prevents complications (hyperglycemia) -​ Factors to consider: -​ Age/weight/activity Cyclically: level/size/development/calorie needs -​ The infusion is given over a shorter period -​ boosted home care program Elderly clients: -​ used to wean client from TPN -​ Over infusion can cause serious adverse effects Solution Administration: -​ May have an underlying clinical problems that affect the outcome of treatment (client Rates of administration – the solution is generally may be taking medications that can started at 25 ml/hr and the rate is gradually interact with TPN components increased. The purpose is to allow the body to adapt to the high concentration of sugar in the solution. Control device – to assure the accuracy of the infusion rate, TPN should be administered via an IV control device, preferably a volumetric pump -​ Inline filters are used in the administration. 0.22 micron filter removes most particulates and any organisms which might be present in the solution -​ Check the order provided by the doctor against the label on the TPN solution container -​ Label the container with expiration date, time at which the solution was hung, glucose concentration, and total volume of solution -​ Maintain flow rates as prescribed, even if the flow falls behind schedule. Don’t allow TPN solutions to hang for more than 24 hours  Insulin therapy -​ Insulin therapy is the primary treatment for all patients with Type 1 diabetes and some Type 2 diabetics who are not adequately controlled by diet and or oral hypoglycemic agents. -​ Each patient’s dose of insulin is individualized to maintain euglycemia( a normal concentration of glucose in the blood), in order to avoid hypoglycemia, Discontinuing therapy hyperglycemia or ketoacidosis and avoid -​ Client receiving TPN should be WEANED long-term complications. from therapy and should receive other form of nutritional therapy such as enteral feedings over 24 hours to prevent rebound hypoglycemia -​ Client receiving PPN can be discontinued without weaning because the dextrose concentration is lower than in TPN Evaluation: -​ Solution is infused at prescribed rate and tolerated by the client -​ Dressing remains dry and intact during interval changes -​ Insertion site remains free of infection and inflammation -​ Client receives nutrients necessary for tissue repair and sustenance -​ Client and family understand procedure and infuse TPN correctly Insulin Administration Insulin is secreted by the beta cells of the islets of Langerhans and lowers the blood glucose level after meals by facilitating the uptake and utilization of glucose by muscle, fat and liver cells. In the absence of adequate insulin, pharmacologic therapy is essential. The storage and metabolism of carbohydrates, proteins, and fats are controlled by insulin, particularly in the liver, muscle, and adipose tissue It is the key that unlocks the door to the cell allowing Short –acting insulins transport of nutrients inside. Regular insulin(marked R on the bottle) A clear solution and is usually given 15 minutes Because of the insulin deficiency of beta cells, before a meal, either alone or in a combination with patients with type 1 diabetes will require a longer-acting insulin. administration of exogenous (originating outside an Can be administered IV organ) insulin to maintain blood glucose control. Usually given 20-30 minutes before a meal; may be taken alone or in combination with long-acting Patients with type 2 diabetes produce insulin and insulin have functioning beta cells. Intermediate-acting Insulins: Patients with type 2 diabetes may require insulin if Are called NPH insulin (neutral protamine diet, exercise, weight reduction and oral Hagedorn) or Lente insulin. hypoglycemia do not maintain adequate blood Similarly in the time course of action , it appears sugar control. white and cloudy. If NPH or Lente insulin is taken alone, it is not crucial that it be taken before a meal but patients should eat some food around the time of the onset As an alternative to needle injections, jet injection and peak of these insulins. devices deliver insulin through the skin under Usually taken after food pressure is an extremely fine stream. These devices are more expensive and require Very long acting-insulins thorough training and supervision when first used. “Peakless” basal insulin In addition, patients should be cautioned that the insulin is absorbed very slowly over 24 hrs and absorption rates, peak insulin activity, and insulin can be given once a day levels may be different when changing to a jet Because the insulin is in the suspension with a pH injector.(Insulin given by jet injector is usually of 4, it cannot be mixed with other insulins because absorbed faster.) this would cause precipitation. Used for basal dose. Insulin Pump Therapy Rapid-acting inhaled insulin For types 1 and 2 diabetes mellitus was appoved by the FDA in June 2014 It is regular insulin but is considered rapid-acting because it peaks at 12-15 minutes and returns to baseline levels at about 160 minutes. Used as rapid-acting insulin Rapid - acting Insulin Produce a more rapid effect that is of shorter duration than regular insulin. Because of their rapid onset, the patient should be instructed to eat no more than 5-15 minutes after injection. INSULIN PUMPS Used for rapid reduction of glucose level Continuous subcutaneous insulin infusion involves the use of small, externally worn devices (insulin METHODS OF INSULIN DELIVERY pumps) that closely mimic the functioning of the normal pancreas. Insulin Pens Insulin pumps contain a 3-mL syringe attached to a -​ Insulin pens use small (150-to 300- unit) long (24-to 42- in) thin, narrow-lumen tube with a pre-filled insulin cartridges that are loaded needle or Teflon catheter attached to the end. into a penlight holder. The patient inserts the needle or catheter into -​ A disposable needle is attached to the subcutaneous tissue (usually on the abdomen) and device for insulin injection. secures it with tape or a transparent dressing. -​ Insulin is delivered by dialing in a dose or The needle or catheter is changed at least every 3 pushing a button for every 1- or 2- unit days. increment given. The pump is then worn either on the patient’s -​ People using these devices still need to clothing or in a pocket. insert the needle for each injection (see Some women keep the pump tucked into the front Fig. 51-3); however, they do not need to or side of the bra. carry insulin bottles or draw up insulin before each injection. -​ These devices are most useful for patients EDUCATING PATIENTS TO SELF- ADMINISTER who need to inject only one type of insulin INSULIN at a time (e.g, premeal rapid acting insulin Insulin injections are self-administered into the three times a day and bedtime NPH subcutaneous tissue with the use of special insulin insulin) or who can use the premixed syringes. insulins. Basic information includes explanations of the -​ These pens are convenient for those who equipment, insulins, and syringes and how to mix administer insulin before dinner if eating insulin, if necessary. out or traveling. -​ They are also useful for patients with impaired manual dexterity, vision, or STORING INSULIN cognitive function, which makes the use of Whether insulin is the short- or the long-acting traditional syringes difficult. preparation, vials not in use, including spare vials or pens, should refrigerated JET INJECTORS Extremes of temperature should be avoided; insulin Most ( if not all) of the printed materials available on should not be allowed to freeze and should not be insulin dose preparation instruct patients to inject air kept in direct sunlight or in a hot car. into the bottle of insulin equivalent to the number of units of insulin to be withdrawn. The insulin vial in use should be kept at room The rationale for this is to prevent the formation of a temperature to reduce local irritation at the injection vacuum inside the bottle , which would make it site, which may occur if cold insulin is injected. difficult to withdraw the proper amount of insulin. If a vial of insulin is used up within 1 month, it may SELECTING AND ROTATING THE INJECTION be kept at a room temperature. SITE The four main areas for injection are the abdomen, The patient should be instructed always to have a upper arms (posterior surface), thighs ( anterior spare vial of the type or types of insulin that he or surface), and hips. she uses. Insulin is absorbed faster in some areas of the body Cloudy insulins should be mixed by gently inverting than others. the vial or rolling it between the hands before The speed of absorption is greatest in the abdomen drawing the solution into a syringe or a pen. and decreases progressively in the arm, thigh, and The patient needs to be educated to pay attention hip, respectively. to the expiration date on any type of insulin Systematic rotation of injection sites within an anatomic area is recommended to prevent localized Bottles of intermediate-acting insulin should also be changes in fatty tissue (lipodystrophy). inspected for flocculation, which is frosted, whitish In addition, to promote insulin absorption, the coating inside the bottle. This occurs most patient should be encouraged to use all available commonly with insulins that are exposed to injection sites within one area rather than randomly extremes of temperature. rotating sites from area to area. If a frosted, adherent coating is present , some of the insulin is bound , inactive, and should not be used. PREPARING THE SKIN The use of alcohol to cleanse the skin is not SELECTING SYRINGES necessary, but patients who have learned this Syringes must be matched with the insulin technique often continue to use it. concentration (e.g.., U-100). Currently, three sizes They should be cautioned to allow the skin to dry of U-100 insulin syringes are available: after cleansing with alcohol 1-ml syringe,100-unit capacity If the skin is not allowed to dry before the injection, 0.5-ml syringe, 50-unit capacity the alcohol may be carried into the tissues, resulting 0.3-ml syringe, 30-unit capacity in localized reddened areas and a burning sensation. The concentration of insulin used in the United States is U-100; that is, there are 100 units per INSERTING THE NEEDLE milliliter ( or cubic centimeter). There are varying approaches to inserting the needle for insulin injections. Small syringes allow patients who require small The correct technique is based on the need for the amounts of insulin to measure and draw up the insulin to be injected into the subcutaneous tissue. amount of insulin accurately. Injection that is too deep or too shallow (intradermal) may affect the rate of absorption of the There is a U-500 (500 units/mL) concentration of insulin. insulin available by special order for patients who For a normal or overweight person, a 90-degree have severe insulin resistance and require massive angle is the best insertion angle. doses of insulin. Aspiration(inserting the needle and then pulling MIXING INSULIN back on the plunger to assess for blood being When rapid- or short-acting insulins are to be given drawn into the syringe and needle in vein) simultaneously with longer-acting insulins, they are Many patients who have been using insulin for an usually mixed together in the same syringe; extended period have eliminated this step from their The longer- acting insulins must be mixed insulin injection routine with no apparent adverse thoroughly before drawing into the syringe. effects. It is important that patients prepare their insulin injections consistently from day to day. INJECTION TECHNIQUE Withdrawing insulin Before each injection, the hands and the injection INJECTION PROCEDURES site should be clean. The top of the insulin vial should be wiped with 70% isopropyl alcohol. Injections are made into the subcutaneous tissue. The vial should be gently rolled in the palms of the Most individuals are able to lightly grasp a fold of hands (not shaken) to resuspend the insulin. skin and inject at a 90 angle. Thin individuals or children can use short needles or may need to An amount of air equal to the dose of insulin pinch the skin and inject at a 45 angle to avoid required should first be drawn up and injected into intramuscular injection, especially in the thigh area. the vial to avoid creating a vacuum. Routine aspiration (drawing back on the injected syringe to check for blood) is not necessary. For a mixed dose, putting sufficient air into both bottles before drawing up the dose is important. If an injection seems especially painful or if blood or When mixing rapid-or short-acting insulin with clear fluid is seen after withdrawing the needle, the intermediate- or long-acting insulin, the clear rapid- patient should apply pressure for 5-8 without or short-acting insulin should be drawn into the rubbing. Blood glucose monitoring should be done syringe first. more frequently on a day when this occurs. After the insulin is drawn into the syringe, the fluid INJECTION OF INSULIN should be inspected for air bubbles. Pain with the insulin injection can be minimized by: -​ Injecting insulin at room temperature. Insulin Injection sites -​ Ensuring no air bubbles are in the syringe prior to injection. -​ Allowing topical alcohol to evaporate prior to injection. -​ Using a quick wrist motion to puncture the skin quickly -​ Avoiding reuse of needles DISPOSING SYRINGES AND NEEDLES -​ Insulin syringes and pens, needles, and lancets should be disposed of according to local regulations. -​ If community disposal programs are unavailable, used sharps should be placed in a puncture- resistant container. -​ The patient should contact local trash INSULIN PUMPS authorities for instructions about proper Insulin may be injected into the subcutaneous disposal of filled containers, which should tissue of the upper arm, the anterior and lateral not be mixed containers to be recycled. aspects of the thigh, the buttocks, and the abdomen Intramuscular injection is not recommended for routine injections. Rotation of the injection site is important. Rotating within one area is recommended to decrease variability in absorption from day to day. The abdomen has the fastest rate of absorption, followed by the arms, thighs, and buttocks. Exercise increases the rate of absorption from injection sites, by increasing blood flow to the skin and also by local actions. Areas of lipodystrophy usually show slower absorption. The rate of absorption also differs between subcutaneous and intramuscular sites.