Digestive and Gastrointestinal Function PDF

UNIT 9 CHAPTERS CHAPTER 38 DIGESTIVE AND...

UNIT 9 CHAPTERS CHAPTER 38 DIGESTIVE AND 38 Assessment of Digestive and Gastrointestinal Function Assessment of Digestive GASTROINTESTINAL 39 Management of Patients with Oral & Esophageal Disorders and Gastrointestinal FUNCTION 40 Management of Patients with Gastric & Duodenal Disorders Function Professor: Joseph Christian G. Bacleon, RN 41 Management of Patients with Intestinal & Rectal Disorders Anatomic and Physiologic Overview ESOPHAGUS GASTROINTESTINAL (GI) TRACT § located in the mediastinum § anterior to the spine and posterior to the § a pathway trachea and heart. § 7 to 7.9 m (23 to 26 feet) in length § a hollow muscular tube § approximately 25 cm (10 inches) in length § extends from the mouth to the esophagus, stomach, small and large intestines, and rectum, to the terminal structure, the anus Diaphragmatic hiatus (esophageal hiatus) § passes through the diaphragm at an opening STOMACH STOMACH IVC § left upper portion of the abdomen Four anatomic regions § under the left lobe of the liver and the diaphragm 1. Cardia (entrance) § overlaying most of the pancreas 2. Fundus § hollow muscular organ (capacity: approx. 1500mL) 3. Body 4. Pylorus (outlet) FUNCTION: Ø stores food during eating Pyloric Sphincter Ø secretes digestive fluids § formed by circular smooth muscle Ø propels the partially digested food (chyme) into the small intestine. (from the wall of the pylorus) § controls the opening between the stomach and the small intestine. DIAPHRAGMATIC HIATUS  SMALL INTESTINE SMALL INTESTINE § longest segment of the GI tract Absorption § folds back and forth on itself § process by which nutrients enter § approx. 70 m (230 feet) the bloodstream through the intestinal walls THREE SECTIONS: 1. Duodenum (the most proximal section) Ileocecal Valve 2. Jejunum (middle section) § where ileum terminates at the 3. Ileum (distal section) cecum APPENDIX COMMON BILE DUCT (CBD) § also known as vermiform appendix § empties into the duodenum at the ampulla of Vater § attached to the cecum § allows for the passage of both bile and pancreatic § an appendage that has little or no secretions. physiologic function. § The ‘Safe House’ Theory of the Appendix LARGE INTESTINE LARGE INTESTINE § also called the large bowel or colon SIGMOID COLON, THE RECTUM, AND THE ANUS § where food waste is formed into poop, stored, and finally excreted. § completes the terminal portion of the large intestine. § It includes the colon, rectum and anus. § a network of striated muscle that forms both the internal and the external anal sphincters regulates the anal outlet. consists of: a. ascending segment (right side of the abdomen) b. transverse segment (extends from right to left in the upper abdomen) c. descending segment (left side of the abdomen) GI TRACT BLOOD SUPPLY PORTAL VENOUS SYSTEM § RECEIVES: blood from arteries This portal venous system is composed of five large veins: (thoracic and abdominal aorta) 1. Superior mesenteric veins 2. Inferior mesenteric veins § RETURNS: blood through veins 3. Gastric veins (from the digestive organs & the 4. Splenic veins spleen) 5. Cystic veins à eventually form the vena portae that enters the liver. 6. Once in the liver, the blood is distributed throughout and collected into the hepatic veins that then terminate in the inferior vena cava. AUTONOMIC NERVOUS SYSTEM AUTONOMIC NERVOUS SYSTEM INVOLUNTARY & VOLUNTARY EFFECTS ON GI TRACT INVOLUNTARY & VOLUNTARY CONTROLS ON GI TRACT INVOLUNTARY CONTROL VOLUNTARY CONTROLS SYMPATHETIC NERVES § upper esophageal sphincter § exert an inhibitory effect on the GI tract § external anal sphincter § decreased gastric secretion and motility § constriction of sphincters and blood vessels PARASYMPATHETIC NERVES § peristalsis § increased secretory activities § relaxing of the sphincters Function of the Digestive System Chewing and Swallowing § Digestion CHEWING § first step of the process of digestion § Absorption § Ptyalin, or salivary amylase – enzyme that begins the digestion of § Elimination starches. SWALLOWING § begins as a voluntary act; regulated by the swallowing center in the medulla oblongata of the CNS. § swallowed food à epiglottis covers tracheal opening à upper esophagus à esophageal peristalsis à lower esophageal sphincter relaxes à stomach à lower esophageal sphincter closes tightly (prevent reflux of stomach contents into the esophagus) Gastric Function STOMACH § stores and mixes food with secretions § secretes a highly acidic fluid (up to 2.4 L/day) in response to the presence or anticipated ingestion of food HYDROCHLORIC ACID (HCl) § pH as low as 1 § secreted by the glands of the stomach § breaks down food into more absorbable components § aid in the destruction of most ingested bacteria. Gastric Function Small Intestine Function PEPSIN § digestive process continues in § an enzyme for protein digestion the duodenum DUODENAL SECRETIONS INTRINSIC FACTOR § a protein that helps your intestines absorb vitamin B12. § from accessory digestive § absorption site: ileum organs – pancreas, liver, and § secreted by the gastric mucosa gallbladder, intestinal glands § absence of intrinsic factor à vitamin B12 cannot be absorbed à pernicious anemia results § these secretions contains digestive enzymes: amylase, CHYME lipase, and bile. § the partially digested food mixed with gastric secretions Small Intestine Function Small Intestine Function Small Intestine Function Pancreatic secretions Pancreatic secretions flow: BILE § have an alkaline pH (high concentration of bicarbonate) § these secretions drain into the § secreted by the liver pancreatic duct à which empties § stored in the gallbladder 1. Trypsin into the common bile duct at the § aids in emulsifying ingested fats § aids in digesting protein ampulla of Vater. 2. Amylase SPHINCTER OF ODDI § aids in digesting starch § found at the confluence of the common bile duct and duodenum 3. Lipase § controls the flow of bile. § aids in digesting fats Small Intestine Function Small Intestine Function TWO TYPES OF INTESTINAL CONTRACTIONS VILLI § small, fingerlike projections Segmentation contractions § lines the entire intestine § produce mixing waves that move the intestinal contents back and § functions to produce digestive enzymes as well as to absorb nutrients forth in a churning motion. _________________ is the major function of the small intestine. § accomplished by active transport and diffusion across the intestinal wall into Intestinal peristalsis the circulation. § propels the contents of the small intestine toward the colon. § Vitamin B12 and bile salts are absorbed in the ileum. Both movements are stimulated by the presence of chyme. Colonic Function Colonic Function Waste Products of Digestion § Within 4 hours after eating Gut microbes (_________) Fecal matter (75% fluid + 25% solid material) à residual waste material § a major component of the contents of the large intestine passes into the terminal § assist in completing the breakdown of waste material § BROWN COLOR ileum à slowly into the ü results from the breakdown of bile by the intestinal bacteria proximal portion of the Two types of colonic secretions are added to the residual material: right colon through the § an electrolyte solution (bicarbonate solution that acts to neutralize the end § FECAL ODOR products formed by the colonic bacterial action) ü from the chemicals formed by intestinal bacteria ileocecal valve. § mucus (protects the colonic mucosa from the intraluminal contents and ü gases formed contain methane, hydrogen sulfide, and ammonia à which provides adherence for the fecal mass) are either absorbed into the portal circulation and detoxified by the liver § ileocecal valve opens briefly and permits some of the or expelled from the rectum as flatus. contents to pass into the colon. Waste Products of Digestion Gut Microbiome Gut Microbiome ELIMINATION Gut microbiota (the complement of microbes in the GI tract) INTESTINAL EPITHELIUM 1. begins with distention of the rectum a. role in vitamin synthesis § is the first line of defense against pathogenic microbes and microbial agents 2. initiates reflex contractions of the rectal musculature b. immune function (protection against invading pathogens, (contains innate immune cells such as macrophages, dendritic cells, 3. relaxes the normally closed internal anal sphincter (controlled by ANS - regulatory influences on innate and adaptive immune responses, granulocytes, and mast cells, and has a role in T-cell responses) involuntary) and inflammation) 4. external sphincter (conscious control of the cerebral cortex – voluntary) = DEFECATION § Defecation is seen to be a spinal reflex (involving the parasympathetic nerve fibers) that can be inhibited voluntarily by keeping the external anal sphincter closed. Gut Microbiome Health History PEYER’S PATCHES (GUT-ASSOCIATED LYMPH TISSUE) ASSESSMENT OF THE q A focused GI assessment begins with a complete history. § also have a role in antigen processing and immune defense GASTROINTESTINAL Common Symptoms: § abdominal pain SYSTEM § § § dyspepsia gas nausea and vomiting § diarrhea § constipation § fecal incontinence § jaundice PAIN DYSPEPSIA REFERRED ABDOMINAL PAIN COMMON SITES Abdominal Pain § upper abdominal discomfort associated with eating (commonly § a frequent presenting problem in general practice called indigestion) § most common symptom of patients with GI dysfunction ü character ü duration Fatty foods (causes the most discomfort because they remain in the ü pattern stomach for digestion longer than proteins or carbohydrates) ü frequency ü location ü distribution of referred abdominal pain ü time of the pain INTESTINAL GAS NAUSEA & VOMITING NAUSEA & VOMITING accumulation of gas in the GI tract may result in: NAUSEA MALLORY-WEISS TEAR § Belching (expulsion of gas from the stomach through the mouth) § a vague, uncomfortable sensation of sickness or “queasiness” § acute onset of emesis that appears bright red or as coffee grounds § Flatulence (expulsion of gas from the rectum) § indicates upper GI bleeding VOMITING § forceful emptying of the stomach and intestinal contents through the mouth EMESIS OR VOMITUS, may contain: § undigested food particles § blood (hematemesis) § bilious material mixed with gastric juices.  CHANGE IN BOWEL HABITS AND CHANGE IN BOWEL HABITS AND STOOL CHARACTERISTICS STOOL CHARACTERISTICS DIARRHEA CONSTIPATION § an abnormal increase in the frequency and liquidity of the stool § a decrease in the frequency of stool, or stools that are hard, dry, and § commonly occurs when the contents move so rapidly through the of smaller volume than typical intestine and colon that there is inadequate time for the GI § may be associated with anal discomfort and rectal bleeding secretions and oral contents to be absorbed. CHANGE IN BOWEL HABITS AND CHANGE IN BOWEL HABITS AND FOODS AND MEDICATIONS THAT STOOL CHARACTERISTICS STOOL CHARACTERISTICS ALTER STOOL COLOR STOOL CHARACTERISTICS LOWER RECTAL OR ANAL BLEEDING § normally light to dark brown § streaking of blood on the surface of the stool ALTERING SUBSTANCE COLOR § blood is noted on toilet tissue Leafy green vegetables, spinach, kale Green TARRY-BLACK COLOR (MELENA) Beets, red gelatin, tomato soup, food coloring Red § upper GI tract bleeding Bismuth, iron, black licorice Black BRIGHT OR DARK RED (HEMATOCHEZIA) Barium Milky white § lower GI tract bleeding PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT ORAL CAVITY ABDOMEN INSPECTION AND PALPATION INSPECTION, AUSCULTATION, PERCUSSION, AND PALPATION § remove dentures for good visualization § patient lies supine with knees flexed slightly § divide into either four quadrants or nine regions LIPS (check for moisture) GUMS (check for inflammation, bleeding, retraction, & discoloration) TONGUE (texture, color, and lesions & cranial nerve XII) PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT ABDOMEN ABDOMEN INSPECTION AUSCULTATION § note skin changes, nodules, lesions, scarring, discolorations, § always precedes percussion and palpation, because they may alter inflammation, bruising, or striae. sounds. § contour and symmetry § localized bulging, distention, or peristaltic waves Indications: § to determine character, location, and frequency of bowel sounds Normal Contour: flat, rounded, or scaphoid and to identify vascular sounds. PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT ABDOMEN ABDOMEN AUSCULTATION AUSCULTATION GUIDE: § use: ______________ of stethoscope § auscultate for a minimum of 5 minutes § listen for at least 1 minute in each quadrant (to confirm the absence BOWEL SOUNDS: of bowel sounds) § frequency (occur irregularly and range from 5 – 30/min) § Borborygmus (“stomach growling”) § character of the sounds (clicks and gurgles) § heard as a loud prolonged gurgle § designated as (normal, hyperactive, hypoactive, or absent) PHYSICAL ASSESSMENT ABDOMEN PERCUSSION § used to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-filled, or solid masses § can validate palpation findings § all quadrants are percussed for overall tympani and dullness. Ø Tympani (sound that results from the presence of air in the stomach and small intestines) Ø Dullness (heard over organs and solid masses) PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT ABDOMEN RECTUM PALPATION INSPECTION AND PALPATION § Light Palpation (identifying areas of tenderness or muscular § evaluation of the terminal portions of the GI tract, the rectum, resistance) perianal region, and anus. § Deep Palpation (used to identify masses) Positions for the rectal examination: § knee-chest § left lateral with hips and knees flexed § standing with hips flexed PHYSICAL ASSESSMENT RECTUM INSPECTION AND PALPATION Internal examination § performed with a gloved lubricated index finger inserted into the anal canal while the patient bears down. § tone of the sphincter is noted, as are any nodules or irregularities of the anal ring. External examination § inspection for lumps, rashes, inflammation, excoriation, tears, scars, pilonidal dimpling, and tufts of hair at the pilonidal area. DIAGNOSTIC GENERAL PREPARATION Preparation for many of these studies includes: SERUM LABORATORY STUDIES § CBC, also known as ______________ EVALUATION § clear liquid or low residue diet § Complete Metabolic Panel § fasting § Prothrombin time/Partial thromboplastin time § ingestion of a liquid bowel preparation § Triglycerides § Liver function tests § the use of laxatives or enemas § Amylase, and Lipase § ingestion or injection of a contrast agent or a radiopaque dye § Tumor markers: Carcinoembryonic antigen (CEA), cancer antigen (CA) 19-9, and alpha-fetoprotein – to detect _________ & _____ cancer STOOL TESTS STOOL TESTS BREATH TESTS - determines consistency, color, and occult (not visible) blood. Guaiac-based fecal occult blood testing (gFOBT) Hydrogen Breath Test § most performed stool test § determines the amount of hydrogen expelled in the breath after it § Fecal urobilinogen § used to find occult blood (or blood that can't be seen with the naked has been produced in the colon (on contact of galactose with § Fecal fat eye) in stool fermenting bacteria) and absorbed into the blood. § Clostridium difficile, and other pathogen/parasites § contraindication: hemorrhoidal bleeding § developed to evaluate carbohydrate absorption, bacterial § Fecal leukocytes § avoid: red meats, aspirin, vitamin C, and NSAIDs for 72 hours prior to overgrowth in the intestine and short-bowel syndrome the study Urea breath tests FIT-fecal DNA testing § detect the presence of Helicobacter pylori (H. pylori metabolizes urea § can detect abnormal sections of DNA from cancer or polyp cells rapidly, the labeled carbon is absorbed quickly) § After the patient ingests a capsule of carbon-labeled urea, a breath sample is obtained 10 to 20 minutes later. ABDOMINAL ULTRASONOGRAPHY ENDOSCOPIC ULTRASONOGRAPHY (EUS) ABDOMINAL ULTRASONOGRAPHY § high-frequency sound waves are passed into internal body NURSING INTERVENTIONS structures § patient is instructed to fast for 8 to 12 hours before ultrasound § indications: enlarged gallbladder or pancreas, the presence of (decreases the amount of gas in the bowel) gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis. § gallbladder studies: the patient should eat a fat-free meal the evening before the test. Endoscopic ultrasonography (EUS) § a specialized enteroscopic procedure that aids in the diagnosis of GI disorders by providing direct imaging of a target area. IMAGING STUDIES IMAGING STUDIES Upper Gastrointestinal Tract Study Upper Gastrointestinal Tract Study: VARIATIONS § An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent. 1. Double-contrast Studies § outlines the stomach and esophageal wall § detect or exclude anatomic or functional disorders of the upper GI organs or sphincters. 2. Enteroclysis § study of the entire small intestine that involves the continuous § Agent: Radiopaque liquid (barium sulfate) infusion (through a duodenal tube) § Nursing Responsibility: Low residue or clear liquid diet, and nothing by mouth (NPO) before the study IMAGING STUDIES IMAGING STUDIES IMAGING STUDIES Lower Gastrointestinal Tract Study Lower Gastrointestinal Tract Study: Nursing Responsibilities § Computed Tomography (cross-sectional images of abdominal § visualization of the lower GI tract is obtained after rectal installation organs and structures) of barium. § preparation of the patient: emptying and cleansing the lower bowel. Ø low residue diet 1 to 2 days before the test § Magnetic Resonance Imaging (useful in evaluating abdominal soft § barium enema: to detect the presence of polyps, tumors, or other Ø clear liquid diet tissues as well as blood vessels, abscesses, fistulas, neoplasms, and lesions of the large intestine and demonstrate any anatomic Ø laxative the evening before other sources of bleeding) abnormalities or malfunctioning of the bowel. Ø NPO after midnight Ø cleansing enemas until returns are clear the following morning. § patient may feel some cramping or discomfort * both can be PLAIN & WITH CONTRAST IMAGING STUDIES IMAGING STUDIES ENDOSCOPIC PROCEDURES Positron Emission Tomography (PET Scan) Scintigraphy § Upper GI Fibroscopy or Esophagogastroduodenoscopy (EGD) Ø scan is an imaging test that can help reveal the metabolic or biochemical § relies on the use of radioactive isotopes function of tissues and organs. § to reveal displaced anatomic structures, changes in organ size, and § Colonoscopy Ø PET scan uses a radioactive drug (tracer) to show both normal and the presence of neoplasms or other focal lesions such as cysts or § Anoscopy abnormal metabolic activity abscesses. § Proctoscopy Gastrointestinal Motility Studies § Sigmoidoscopy § used to assess gastric emptying and colonic transit time. § Small-bowel enteroscopy § Endoscopy through an ostomy GASTROSCOPY ANOSCOPY  PROCTOSCOPY ENDOSCOPIC PROCEDURES Nursing Interventions: Upper GI Endoscopy § patient should be NPO for 8 hours prior to the examination § patient is given a local anesthetic gargle or spray (if endoscope is introduced via mouth) Ø Midazolam (a sedative that provides moderate sedation with loss of the gag reflex and relieves anxiety during the procedure) Ø Atropine (to reduce secretions, and glucagon may be given to relax smooth muscle) ENDOSCOPIC PROCEDURES Manometry Test Electrophysiologic Studies Nursing Interventions: Lower GI Endoscopy (colon etc.) § methods for evaluating patients with GI motility disorders. Rectal sensory function studies § used to evaluate rectal sensory function and neuropathy § Adequate colon cleansing (for optimal visualization) MANOMETRY TEST § Pre-procedure diet: clear liquid or a low residue diet § measures changes in intraluminal pressures and the coordination of Electrogastrography (electrophysiologic study) muscle activity in the GI tract § to assess gastric motility disturbances § use of lavage solutions § detects motor or nerve dysfunction in the stomach. § may experience abdominal cramping due to increased peristalsis Ø Esophageal manometry § Post-procedure: inspect for signs and symptoms of bowel perforation (rectal Ø Gastroduodenal, small intestine, and colonic manometry bleeding, abdominal pain or distention, fever, focal peritoneal signs) Gastric Analysis Gastric Acid Stimulation Test pH Monitoring to determine: § performed in conjunction with gastric analysis § A sensor that measures pH is inserted and positioned via § secretory activity of the gastric mucosa § Histamine or pentagastrin is given subcutaneously to stimulate endoscopy. § the presence or degree of gastric retention gastric secretions. INDICATION: Important Diagnostic Information: § esophageal reflux of gastric acid (evaluated by ambulatory pH § Pernicious anemia: secrete no acid under basal conditions or after monitoring) stimulation. § § Severe chronic atrophic gastritis or gastric cancer: secrete little or no acid. § Gastric ulcer: secrete some acid. § Duodenal ulcers: usually secrete an excess amount of acid. Laparoscopy (Peritoneoscopy) § minimally invasive surgery, diagnostic laparoscopy § a very small incision is made - lateral to the umbilicus EXAMPLE PROCEDURE § permits direct visualization of the organs and structures within the LAPAROSCOPIC abdomen, permitting visualization and identification of any growths, CHOLECYSTECTOMY anomalies, and inflammatory processes. § requires general anesthesia and sometimes requires that the stomach and bowel be decompressed SPECIAL DIETS GASTROINTESTINAL CLEAR LIQUID DIET § limited to water, tea, coffee, clear broths, TREATMENT § ginger ale, strained and clear juices and plain gelatin § this diet provides the client with fluid and carbohydrate in § the form of sugar but does not supplement adequate protein, fats, MODALITIES vitamins, minerals or calories. § it is short term diet 24 to 36 hours § the major objective of this diet is to relieve thirst, prevent dehydration, minimize stimulation of the GIT SPECIAL DIETS FULL LIQUID DIET § diet contains only liquids or foods that turn to liquid at body temperature, like: ü Ice cream ü Vegetable juices ü Refined or strained cereals ü Yogurt ü milk and milk drinks SPECIAL DIETS SPECIAL DIETS Gastrointestinal Intubation DIET AS TOLERATED (DAT) ENTERAL NUTRITION § is the insertion of a flexible tube § is ordered when the client’s appetite, ability to eat and tolerance for § NGT feeding certain foods may change. § Gastrostomy feeding (done to clients at risk for aspiration) into the stomach, or beyond the § Normal intestinal motility has returned with active bowel sound and § Decrease level of consciousness pylorus into the duodenum (the client reports passing gas § Poor cough, gag reflex § Inability to participate in feeding , restlessness/agitation first section of the small intestine) or the jejunum (the second section of the small intestine). Gastrointestinal Intubation Tube Types § Decompress the stomach and remove gas and fluid Levin Tube § single lumen (channel within a tube or catheter) and is made of § Lavage (flush with water or other fluids) the stomach and remove plastic or rubber. ingested toxins or other harmful materials Salem Sump § Diagnose GI disorders § is a radiopaque (easily seen on x-ray), clear plastic, double-lumen § Administer tube feedings, fluids, and medications gastric tube. § Compress a bleeding site § Aspirate GI contents for analysis ENTERAL NUTRITION ENTERAL NUTRITION ENTERAL NUTRITION § Enteral nutrition, also known as tube feeding, is a way of delivering Types of Tube Feedings Administering Tube Feedings nutrition directly to your stomach or small intestine. Several types of tubes are used for enteral feeding: Indication: oral intake is inadequate or not possible § Feeding via the enteric route (intestines are receiving nutrients) § Nasogastric tubes (NGT) Route: delivered to the stomach, duodenum, or proximal jejunum § Nasojejunal tube (NJT) § Delivering enteral nutrition – refers to infusing nutritional formula § Jejunostomy tubes (JEJ, PEJ or RIJ tubes) Advantages feedings through a tube directly into the GI tract. § Radiologically inserted gastrostomy tube (RIG) § lower in cost, safer § Percutaneous endoscopic gastrostomy tubes (PEG tube) § usually well tolerated by the patient § easier to use in extended care facilities or patient’s home. ENTERAL NUTRITION ENTERAL NUTRITION Conditions That May Require Enteral Therapy OSMOLALITY: DUMPING SYNDROME § Alcoholism, chronic depression, anorexia nervosa § concentrated solution of high osmolality (concentration) entering the § Coma (stroke, head injury, neurologic disorder) stomach is taken in quickly or in large amounts, the small intestines § Convalescent care (surgery, injury, severe illness) § Oropharyngeal or esophageal paralysis expand, and water moves rapidly into the intestinal lumen from fluid § GI problems (mild pancreatitis, Crohn’s disease, ulcerative colitis) surrounding the organs and the vascular compartment. § Maxillofacial or cervical surgery ENTERAL NUTRITION ENTERAL NUTRITION OSMOLALITY: DUMPING SYNDROME ADMINISTRATION METHODS Signs & Symptoms: 1. NASOGASTRIC TUBE (NGT) FEEDING § feelings of fullness § short-term feedings, uncomfortable § nausea, cramping 2. BOLUS FEEDINGS § dizziness, diaphoresis § given into the stomach through a large (50-mL) syringe via gravity § osmotic diarrhea § requires dividing the total daily feeding volume into 4 to 6 feeds throughout the day Can lead to: Dehydration, Hypotension, Tachycardia. § typical volume is 200 to 400 mL of feeding Bolus gastrostomy feeding by gravity. ENTERAL NUTRITION ENTERAL NUTRITION Syringe is raised perpendicular to the ADMINISTRATION METHODS ADMINISTRATION METHODS abdomen so that feeding can enter by gravity. 3. GRAVITY FEEDINGS 4. INTERMITTENT GRAVITY DRIP FEEDING METHOD § raising or lowering the syringe above the abdominal wall regulates § requires administering feedings over 30 minutes or longer at the rate of flow. designated intervals by a reservoir enteral bag and tubing § amount and flow rate (determined by the patient’s reaction)( § flow rate regulated by a roller clamp or automated pump. § If the patient feels full – slow the delivery time or give smaller volumes more frequently ENTERAL NUTRITION ENTERAL NUTRITION ADMINISTRATION METHODS ADMINISTRATION METHODS Nasoenteric tube feeding by 5. CONTINUOUS FEEDING continuous controlled pump. 6. CYCLIC FEEDING § delivery of feedings incrementally by a slow infusion over long periods The head of the bed should § alternative to the continuous infusion method be elevated to prevent § Indications: patients who are critically ill patients, high risk for § infused feeding is given by an enteral feeding pump over 8 to 18 hours. aspiration. aspiration, risk for intolerance (pancreatitis), and for small bowel feedings § Enteral feeding pumps control the delivery rate of the formula ENTERAL NUTRITION ENTERAL NUTRITION ENTERAL NUTRITION POTENTIAL COMPLICATIONS OF ENTERAL THERAPY POTENTIAL COMPLICATIONS OF ENTERAL THERAPY KEY NURSING RESPONSIBILITIES: Gastrointestinal: Metabolic: § Assessing Patients Receiving Tube Feedings § Constipation § Dehydration and azotemia (excessive urea in the blood) § Maintaining Feeding Equipment and Nutritional Balance § Diarrhea § Hyperglycemia § Providing Medications by Tube § Gas/bloating/cramping § Refeeding syndrome (due to rapid shifts in intracellular and § Maintaining Delivery Systems § Nausea/vomiting extracellular electrolytes) § Maintaining Normal Bowel Elimination Pattern Mechanical: § Maintaining Adequate Hydration § Aspiration pneumonia § Promoting Coping Ability § Nasopharyngeal irritation § Preventing Dumping Syndrome § Tube displacement § Tube obstruction ENTERAL NUTRITION GASTROSTOMY GASTROSTOMY NOTE: § a surgical procedure TYPES OF GASTROSTOMY TUBE: § opening (stoma) is created into the § For tube feedings longer than 4 weeks, gastrostomy or stomach à houses the tube § PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) jejunostomy tubes are preferred for administration of medications § RADIOLOGICALLY INSERTED GASTROSTOMY TUBE (RIG) PURPOSE: or nutrition. § Administration of nutrition, fluids, and medications via a feeding tube § Gastric decompression (gastroparesis, gastroesophageal reflux disease, or intestinal obstruction)  JEJUNOSTOMY § a surgical procedure (can be done endoscopically or radiologically) § placed opening into the jejunum PURPOSE: § administering nutrition, fluids, and medications § decrease aspiration risk (when the stomach is not functioning adequately to process and empty food and fluids) INDICATION: A detail of the abdomen and the percutaneous A detail of the abdomen and the § gastric route is not accessible endoscopic gastrostomy (PEG) tube showing nonobturated low-profile gastrostomy catheter fixation. device showing balloon fixation. JEJUNOSTOMY GASTROJEJUNOSTOMY GASTROJEJUNOSTOMY § A surgical procedure that connects part of the stomach to the jejunum (the middle part of the small intestine). § allows food and other stomach contents to pass directly from the stomach to the jejunum without passing through the first part of the small intestine called the duodenum. PARENTERAL NUTRITION PARENTERAL NUTRITION Parenteral Nutrition Total Parenteral Nutrition § a method of providing nutrients to the § a feeding technique that avoids the digestive tract. body by an IV route. § most of the body's nutritional requirements are met by a specific formula administered intravenously. Indications: § malnourished Types of Solution: § cannot tolerate receiving nutrition § Amino acid-dextrose formulas (intralipid – 500 ml of 10% fat orally or by the enteral route emulsions) – fine bacterial filter used § Total nutrient admixture (amino acid-dextrose-lipid) – no bacterial filter used PARENTERAL NUTRITION PARENTERAL NUTRITION PARENTERAL NUTRITION METHODS OF ADMINISTRATION: Central venous access devices (CVADs): TOTAL PARENTERAL NUTRITION: INTERVENTIONS § Percutaneous (or nontunneled) 1. PERIPHERAL § Peripherally inserted central catheters (PICCs) § Initial rate of infusion 50ml/hour gradually increased to 100 to § peripheral parenteral nutrition (PPN) § Surgically placed (or tunneled) catheters 125ml/hr. as patient’s fluid and electrolyte permits § Implanted vascular access ports § should not administer dextrose concentrations above 10% due to § Infuse solution by pump at constant rate to prevent abrupt change irritation of vessel walls, usually used for less than 2 weeks. in infusion rate. § Monitor for signs of complications 2. CENTRAL Sepsis § central parenteral nutrition Pneumothorax because of placement lines § catheter is inserted into subclavian vein Hyperosmolar coma – monitor for glucose level & serum osmolality PARENTERAL NUTRITION PARENTERAL NUTRITION TOTAL PARENTERAL NUTRITION: INTERVENTIONS TOTAL PARENTERAL NUTRITION: INTERVENTIONS END! § Change IV tubing and filter every 24 hours DISCONTINUATION § Keep solutions refrigerated until needed; allow to warm to room § gradually tapered – to allow patient to adjust to decreased levels temperature before use of glucose If new solution unavailable, use dextrose 10% and water solution § After discontinuation, isotonic glucose solution administered to § NEXT: CHAPTER 39 until available prevent rebound hypoglycemia; weakness, faintness, diaphoresis, § Monitor daily weights, glucose, temperature, I & O 3x a week shakiness, confusion, tachycardia. 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