enteral nutrition ppt.pptx

ENTERAL NUTRITION Shana Bouley - Spring 2024 - Skills III  Objective of the Lesson Discuss the Principles , procedures and rationales to provide safe delivery of enteral nutrition Purpose and principles of NG, NJ and J- tubes Continuous and intermittent delivery Enteral nutrition...

ENTERAL NUTRITION Shana Bouley - Spring 2024 - Skills III  Objective of the Lesson Discuss the Principles , procedures and rationales to provide safe delivery of enteral nutrition Purpose and principles of NG, NJ and J- tubes Continuous and intermittent delivery Enteral nutrition pump set up Client assessment (site, GI, residual volume (NG), breathing pattern change or the presence of a cough) Verify tube placement Flushing and irrigation Site care and/or dressing change Mouth care and nasal care Securing the tube (NG,NJ) Elevating the head of the bed Report unexpected findings and perform required interventions Document findings and interventions Definition ENTERAL NUTRITION REFERS TO THE DELIVERY OF NUTRITIONAL FORMULAS THROUGH A TUBE THAT HAS BEEN INSERTED INTO THE GASTROINTESTINAL (GI) TRACT. NASOGASTRIC (NG) TUBE ARE DELIVERED THROUGH A FEEDING TUBE INTRODUCED THROUGH THE NOSE INTO THE STOMACH. CAN BE CONTINUOUS, INTERMITTENT, OR BOLUS AND ARE DELIVERED VIA GRAVITY, SYRINGE  What type of patient? CANDIDATES FOR TUBE FEEDING INCLUDE PATIENTS WHO HAVE ADEQUATE DIGESTION AND ABSORPTION BUT CANNOT INGEST, CHEW OR SWALLOW FOOD SAFELY OR IN ADEQUATE AMOUNTS.  What type of patient? FOR LONG-TERM FEEDING (BEYOND 4 WEEKS) OR IN SITUATIONS WHERE ACCESS TO THE GASTROINTESTINAL (GI) TRACT THROUGH THE NOSE OR MOUTH IS CONTRAINDICATED, DIRECT ENTERAL ACCESS THROUGH THE ABDOMINAL WALL MAY BE THE OPTIMAL CHOICE THE STOMACH (GASTROSTOMY TUBE) AND THE JEJUNUM (JEJUNOSTOMY TUBE) ARE THE USUAL SITES FOR LONG-TERM FEEDING TUBES. THE SELECTION OF THE TYPE OF TUBE AND PLACEMENT METHOD DEPENDS ON THE ANTICIPATED DURATION OF FEEDING AND OTHER PATIENT-RELATED FACTORS SUCH AS GASTRIC EMPTYING AND RISK FOR PULMONARY ASPIRATION, THE MOST SERIOUS COMPLICATION OF TUBE FEEDING! FOR SHORT-TERM FEEDING (TEMPORARY), NASAL OR ORAL FEEDING TUBES ARE APPROPRIATE  Different Types Nasogastric Tube is a thin, soft tube made of plastic of Tubes NG or rubber that is passed through the nose, down through the throat, and into the stomach. NASOJEJUNAL TUBE IS A NJ SMALL TUBE PASSED THROUGH THE NOSE AND INTO THE SMALL BOWEL. Jejunostomy tube is a soft, plastic tube placed J through the skin of the abdomen into the midsection of the small intestine.  Different Types of Tubes PLASTIC NASOGASTRIC TUBES: CAN BE USED FOR TUBE FEEDING AND ADMINISTERING MEDICATIONS (PLACED VIA THE NOSE TO THE STOMACH) SMALL-BORE SILICONE FEEDING TUBES: USUALLY USED ONLY FOR TUBE FEEDING (VIA NOSE PLACED IN STOMACH, DUODENUM) G TUBE OR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE USED FOR TUBE FEEDING AND ADMINISTERING MEDICATION (PLACED DIRECTLY IN STOMACH OR INTESTINE (J-TUBE)  Indications for an NG Tube ASPIRATION OF GASTRIC CONTENTS DECOMPRESSION SPECIMEN ANALYSIS GASTRIC LAVAGE: IN CASES OF POISONING OR OVERDOSE OF MEDICATION NUTRITIONAL SUPPORT (USUALLY LESS THAN SIX WEEKS IN DURATION) ADMINISTRATION OF MEDICATION Pictures of Some Different Tubes Patient-Centered Care Nursing responsibilities include caring for the tube, administering nutrient formula, and preventing complications- Pulmonary aspiration is the most serious complication Many social, religious, and cultural events involve food; patients requiring long-term tube feeding may feel a sense of loss regarding their ability to participate in life activities The insertion and use of a feeding tube often raise emotional and psychological concerns. The patient and family caregiver need reassurance and encouragement throughout the insertion procedure and once the tube Patient-Centered Care Nursing interventions such as providing oral hygiene and care of the nasal passage or tube insertion site promote patient comfort during tube feeding and can reduce complications Although tube feeding may off er life-sustaining treatment, artifi cial nutrition can never replace the social and symbolic benefi ts of sharing meals. Studies show that many patients associate tube feeding with low quality of life A multidisciplinary team can help patients and family caregivers use strategies to preserve or enhance quality of life Maintenance of a Nasogastric Tube PROVIDE ORAL AND NASAL HYGIENE CHECK LOCATION OF EXTERNAL EXIT SITE MARKING ON TUBE ANCHOR TUBE TO PATIENT’S GOWN DURING ROUTINE CARE TO PREVENT DISPLACEMENT REPORT ANY SIGNS OF REDNESS OR IRRITATION TO THE NARES. PROVIDE COMFORT MEASURES FOR COMFORT POSITIONING OR OFFERING ICE CHIPS IF ALLOWED. Anchoring the Tape  G Tube When duration of tube feeding is greater than 4 weeks or in situations in which access via the nose or mouth is contraindicated, direct enteral access through the abdominal wall is optimal choice- Gastrostomy Tube (G tube) or Peg Tube  CARE OF GASTROSTOMY OR JEJUNOSTOMY LONG-TERM TUBES REQUIRE ENDOSCOPIC, RADIOLOGIC, OR SURGICAL PLACEMENT. THE INSERTION METHOD USED TO PLACE TUBES MAY CALL FOR SPECIFIC NURSING INTERVENTIONS IN THE POSTINSERTION PERIOD, BUT OTHERWISE THESE TUBES ARE USED IN A SIMILAR WAY TO OTHER FEEDING TUBES FEEDINGS DELIVERED VIA A GASTROSTOMY TUBE ARE RELATIVELY SAFE TO ADMINISTER, PROVIDED THE PATIENT HAS NORMAL GASTRIC EMPTYING  CARE OF GASTROSTOMY OR JEJUNOSTOMY GASTROSTOMY TUBES ARE OFTEN CALLED G TUBES, BUT THEY ARE ALSO COMMONLY REFERRED TO AS PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBES, A TERM USED TO DESCRIBE TUBES PLACED ENDOSCOPICALLY Jejunostomy tubes are indicated when risks for regurgitation and aspiration are especially high, as in cases of severely delayed gastric emptying or in conditions such as pancreatitis, which limit the use of the stomach for feeding Verifying Feeding Tube Placement Monitor the external length of the tube. It is possible for the tip of a feeding tube to move or migrate into a diff erent location Although all tubes should be marked to document correct position, tube dislocation can sometimes occur without any external evidence that the tube has moved After initial x-ray fi lm verifi cation of correct feeding tube position, monitor the tube to ensure that the tube tip remains in the intended site Check feeding tube position at regular intervals and before  Verifying Feeding Tube Placement No single bedside method of monitoring tube position during feeding is completely reliable; use techniques in combination Monitor the external length of the tube and observe the appearance, volume, and pH of fluid aspirated through it. The color of the fluid can help differentiate gastric from intestinal placement Testing the pH of an aspirate at the bedside using pH paper offers some information regarding the position of a feeding tube Obtain repeat x-ray film confirmation if bedside methods create any doubt regarding the location of the tube delegation and collaboration Verification of tube placement cannot be delegated to PSW The nurse directs nursing assistive personnel (NAP) to immediately inform the nurse if: Patient respirations change Patient vomits or PSW notices vomit in patient’s mouth Nasal skin irritation is present External length of tube changes  ADMINISTERING ENTERAL NUTRITION What is the most common type of enteral nutrition?- Gastric feedings Small bowel feeding may reduce risk of aspiration An enteral pump is used to control the administration rate of small bowel and many continuous gastric feedings. An enteral pump may prevent bloating, Delivery of Feeding Intermittent bolu s continuo Nursing Considerations Assessment- verify order, check Bowel sounds, allergies, check gastric residual and placement per facility policy Position pt high fowlers or Elevate the patient’s head to 30- 45 degrees- remain up for duration of feeding and 1hour post feeding. Report any diffi culty infusing the feeding or any discomfort voiced by the patient, including any gagging, paroxysms of coughing, or choking Provide frequent oral hygiene and assess skin around tube insertion site daily Formulas are available in closed system bags containing enough for 24-48 hrs or in an open system where the bag is changed every 24 hr  Gastric Residual Volume Using a 60 ml syringe Draw up and instill 10-30mls of air and slowly inject. Pull back slowly and aspirate all stomach contents you can aspirate Return to stomach slowly is total is less than 250mls Flush with 30mls of H2O Returning aspirate prevents loss of electrolytes and nutrients should fluid be discarded GRV in the range of 200-500mls may increase risk of aspiration Nursing Considerations Formula in an open system bag has a max hang time of 12hr Feedings can be intermittent or continuous or bolus Flush with 30cc water before and after feeding Monitor intake and output q 8hr Weight patient as ordered (daily then 3x/week) Monitor lab values …electrolytes Nursing Considerations Monitor G tube site, change dressing daily and PRN and report any skin irritation or breakdown Tube placement verification and Gastric residual checks every 4-6 hr are completed by the licensed RN, LPN or per facility policy When in doubt of placement- Xray is needed.  COMPLICATIONS ASPIRATIO DIARRHEA N FLUID TRAVELS INTO LUNGS OFTEN DUE TO ALLERGY OR Occurs if: SENSITIVITY Too rapid Bacterial content in bag Lying flat Do not hang > 4 hours Problems with peristalsis Ensure rinsing, flushing  COMPLICATIONS OCCLUSIO DISPLACEM N ENT TUBE GETS BLOCKED AND FEEDING CANNOT BE ADMINISTERED TUBE MOVES OUT OF PLACE From not flushing adequately COUGHING, VOMITING, ABD. PAIN, Meds not crushed enough LEAKING AT SITE Reaction between meds and formula TUBE PLACEMENT MUST ALWAYS Ensure adequate flushing after each BE VERIFIED! feeding and before and after meds  COMPLICATIONS NV + BREAKDOW CRAMPS N RATE TOO HIGH SKIN AROUND TUBE CAN Delayed gastric emptying ERODE Formula cold Movement of tube, Osmolality of formula too moisture at site high Can become infected, Lactose intolerant excessive granulation  FLUSHING / IRRIGATION Feeding tubes must remain patent to ensure that liquid nutritional formulas can pass through easily. All types of feeding tubes require routine irrigation to keep a tube patent. Inability to instill air and fluids suggest that a tube is occluded. Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion.  Equipment needed to irrigate or flush it tube feed : 60 ml syringe water (tap water or sterile water) dated + initial container at patient’s bedside towel clean gloves stethoscope when flushing make sure you have your client  irrigate routinely before between and after medication administration and before an intermittent feeding is administered change irrigation container every 24 hours or according to facility policy Clamp or kink feeding tube while disconnecting it from administration tubing or while removing plug at the end of the tube insert the 60CC syringe into the end of the feeding tube release kink or clamp and slowly and still irrigation solution. If unable to install fluid reposition the client on the left side and try again  Caring for the Site Dressings are changed daily and as needed Determine whether the exit site is left open to air or if a dressing is indicated check healthcare providers prescription + verify employers' policy remove all dressing assess exit site for evidence of tenderness, leakage, swelling, excoriation, infection, bleeding, or excessive movement of the feeding tube  Caring for the Site Clean skin around the exit site with warm water and mild soap or saline Rinse and dry site completely If dressing is prescribed place drain gauze dressing over the external tube secure with tape make sure to date time and initial the new dressing evaluate the condition of the site routinely document accordingly  Care of the Client with Feeding Tube Ongoing assessment and monitoring Respiratory/GI/Integumentary Look for S&S of possible complications…. SOB, vomiting, pain, redness and infection at site, abdominal distension, loose stools Maintain good oral hygiene! Remember √ placement markings Elevate HOB 30o Solution at room temperature Discard prepared formula after 24-48 hrs Mouth care q2h Assess for side effects Administer H2O pre & post feeding & with meds Assess skin integrity Routine irrigation of the tube with H2O prevents tube from becoming occluded by curdled formula or improperly crushed medications. Now we will head into lab to work with the pumps! Scenario - Critical Thinking A patient has been receiving tube feeding running continuously at 50 ml/hr. When refi lling the solution bag, 400 ml of feeding solution is added. One hour later, the nurse enters the room to hear the pump alarming. She notices the feeding bag is empty but knows this should not be the case. When she reviews the pump program, she sees that: the rate has mistakenly been entered as 400 ml/hr nothing has been entered for volume to be delivered (VTBD) The patient states that he has stomach cramps and is feeling nauseated. what are some nursing interventions?