Nutrition and Elimination Procedures PDF

Lesson 3 of 10 Lesson 3- Nutrition and Elimination Procedures After completing this lesson, the student will be able to apply nutrition and elimination procedures in accordance with prescribed guidance and publications. Patient Dietary Considerations As a medical technician, it is important to know...

Lesson 3 of 10 Lesson 3- Nutrition and Elimination Procedures After completing this lesson, the student will be able to apply nutrition and elimination procedures in accordance with prescribed guidance and publications. Patient Dietary Considerations As a medical technician, it is important to know what dietary order each of our patients requires, and why. We must know the level of consciousness, swallow study results as well as the level of assistance they may need, to include any special precautions. Clear Liquids Diet – These consist of fat-free broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices (like apple juice), gelatin, fruit ices (ie: Italian ice) and popsicles. The term clear means you are able to see through it. An example of a non-clear juice would be orange juice. Considerations: patients with potential GI issues, or postsurgical patients, avoid clear liquids that are red/pink, orange or purple, as these can give a false “ bleed” in the patients output. Always ensure the patient is in the sitting position, or elevated head of bed for aspiration precautions. Full Liquid – While keeping clear liquid in mind, this is a step up. Full liquid has the addition of smooth textured dairy such as ice cream, strained or blended cream soups, and custards, refined cook cereals such as cream of wheat, vegetable juice, pureed vegetables, all fruit juices, sherbets, puddings and frozen yogurt. Considerations: Always ensure the patient is in the sitting position, or elevated head of bed for aspiration precautions. Dysphagia Stages – Thickened Liquids, Pureed: This dietary order combines both clear liquid and full liquid dietary orders, with the addition of scrambled eggs; pureed meats, vegetables, and fruits: mashed potatoes and gravy. Considerations: These patients may not have the ability to chew, possibly have dentures, weak facial muscles, or a simply short attention span likely seen in elderly or pediatric patients. Mechanical Soft – Combining the three above, with the addition of all cream soups, ground or finely diced meats, flaked fish (white fish), cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter and eggs (not fried). Soft/Low Residue – Addition of low fiber, easily digested foods such as pasta, casseroles, moist tender meats, canned cooked fruits, vegetables, desserts such as cake and cookies without nuts or coconut. High Fiber – Addition of fresh, uncooked fruits, steam cooked vegetables, bran, oatmeal and dried fruits. Low Cholesterol – 300 milligrams (mg) a day of cholesterol in accordance with the American Heart Association guidelines. Bland Diet – These are ordered for patients who suffer from ulcers or any irritants to the GI tract. These diets are designed to eliminate chemical, mechanical and thermal irritants. This diet consists of foods cooked without oils and seasoning/spices. Fat Restricted – These are ordered for patients with gallbladder disease, malabsorption syndrome, and hyperlipidemia. Protein Restricted – These are ordered for patients who have an impaired ability to excrete waste products of protein due to kidney or liver disease. These vary from total elimination of protein to diets around 80 grams per day. Gluten Free – Eliminates wheat, oats, rye, barley and their derivatives. Calorie Restricted – This diet is designed to either lose weight or maintain a desirable weight. The diets contain fewer calories than the patient normally metabolizes. Foods allowed on a calorie restricted diet include foods that are low in fats and carbs, such as lean meats, fruits, vegetables, while avoiding foods that are high in fat or carbs such as butter, pastas, pastries or potato chips. Mineral Restricted – These diets are ordered to treat certain diseases and conditions for test purposes. This includes: sodium (Na), potassium (K), calcium (Ca), phosphorus, (P), copper (Cu) and oxalate (OX). Low Sodium – These consist of 4 gram (no added salt), 2 and 1 gram, or 500-mg sodium diets. These can vary from no salt, to sever sodium restrictions. Sodium Restricted – Sodium Restricted: Sodium is a mineral commonly found in almost all food and even water. The most common form is sodium chloride or salt. The average daily intake is between 6-18 grams. This diet is ordered for patients who are subject to edema, hypertension, congestive heart failure, renal disease and cirrhosis of the liver. Potassium Restricted – These are ordered for patients with kidney disease. Damaged kidneys have difficulty eliminating potassium. On occasion, some patients have a potassium depletion and require a high-potassium diet. Conditions that require high potassium include pro-longed IV feedings, severe diarrhea, diuretic therapy, diabetic acidosis or renal disease. Calcium Restricted – This diet is ordered for patients who have recurrent renal calculi or hypercalcemia. The average daily intake of calcium is 800 mg. A 400 mg reduction in calcium intake will lower the renal load. Cranberry juice has a strong acidifying effect on urine, and may be effective in increasing urinary calcium excretion. Regular Diet – No restrictions unless specified in the providers orders. C O NT I NU E Procedures to Assist Patients with Feeding Some patients will require assistance during meals. Whether that is setting up their tray, cutting up their food or feeding them at bedside. We need to ensure we are providing patient safety and are aware of the indications and contraindications for each of our patients to include their specific meal orders. The goal is to properly prepare the patient and do everything we can to stimulate their appetite. Step 1 Step One Verify providers orders, and the meal matches the orders listed on Air Force Form 1094. Deliver tray to patient’s bedside Set up overbed table Step 2 Step Two Remove tray lid and open any packages/cartons. Step 3 Step Three Cut up food according to meal orders, patient size and preference. Step 4 Step Four Allow food to cool and ensure napkins, utensils and call bell are within the patient’s reach. Step 5 Step Five Place patient in the sitting position in a chair, or raise the head of the bed to 90 degrees and have oral suction available. Step 6 Step Six Encourage the patient to do as much as possible for themselves. Promote independence and dignity. Step 7 Step Seven Place the tray in a visible and convenient position. Do not show signs of being in a hurry, take your time assisting. Step 8 Step Eight Offer small amounts of various foods, and fluids during the meal. Step 9 Step Nine After the meal, provide post oral hygiene. Step 10 Step Ten Record intake of solids and liquids. Special Considerations Blind patients may be very aware of food aromas, however you may still need to inform the patient what is being served and where it is located on the plate. Use the clock method to describe where foods are located. Set up the table/tray and assist the patient where you placed items (if they are right handed, place items on the right side). Patients with unilateral (one sided) weakness will require monitoring during feeding. Place the food into the stronger side of the mouth. Contraindication of oral feeding are absent gag reflex, dysphagia (difficulty swallowing) or decreased level of alertness. These patients are high risk for aspiration.  DO NOT lower the head of the bed directly after eating. C O NT I NU E Assist/Monitor with Tube Feeding Gastric gavage is the procedure of feeding a patient through a tube inserted through the mouth or nose and into the stomach. The tube may be left in place for several days, or it may be inserted before each feeding. Accurate recording of the patient’s intake and output is important. Ensure you provide oral care according to the provider’s orders. Step 1 Step One Verify provider’s orders and gather the below equipment: Feeding solution Irrigation syringe or funnel Graduated measuring device Water Step 2 Step Two Prior to the procedure, ensure the nasogastric (NG) tube placement is correct. This can be done by auscultation of the abdomen. Ensure the NG tube is secured within the patient’s nose. Step 3 Step Three Place the patient in the Semi- Fowler’s position. This will prevent aspiration as well as promote digestion. Step 4 Step Four Place a drape across the patient’s chest. Step 5 Step Five Keeping the NG tube clamped, connect the irrigation syringe to the end of the tube. Pour the room temperature feeding solution into the funnel. Remove/release the clamp. When the syringe is ¾ empty, pour in additional solution. DO NOT ALLOW AIR INTO THE TUBE. Continue to administer the feeding solution slowly over the next 10- 20 minutes. Slow administration is important to ensure proper digestion, as well as reduce nausea and gaseous air for the patient. The patient may have a full feeling before all nutrients are administered if you pour too much too quickly. When the patient has received the prescribed amount of feeding solution, flush the NG tube with 50mL water. Clamp the tube and keep the patient in the semi-fowlers position. Report and document the procedure. C O NT I NU E Administer Retention Enema One of the main purposes of a retention enema, is to lubricate the feces in the rectum and colon. Often, these are called oil-retention enemas. These are typically for patients who are experiencing constant constipation. The oil needs to be retained in the rectum to soften and coat the hardened feces. Enemas are given to evacuate the bowel. You may use tap water, soapsuds, or saline solution, using either an enema buckets or bag. Step 1 Step Verify provider’s orders, and right patient using two patient identifiers. Plan enough time to either give the oil retention solution, or a large volume enema. Step 2 Step Two Gather the following supplies. Enema container and tubing with clamp, solution or disposable enema, bedpan or bedside commode, chux pad, lubricant, gloves, bath blanket, paper towel and toilet tissue. Step 3 Step Three Place the patient in the left Sims position and drape the patient with a bath blanket. Place the chux pad under the patients buttocks. (The solution will travel up the colon when the patient is laying on their left side. Open your supplies. If the tip of the enema bottle is not lubricated, or seem insufficient, add extra lubricant. Inset the tip into the anal opening. Gently and slowly squeeze the bottle, while rolling it up from the bottom as the solution enters the bowel. Try to squeeze as much of the solution into the patient as you can. Remove the tip slowly, and hold the buttocks together. Step 4 Step Four The oil or solution for a retention enema should be retained for at least 20 minutes and no more than two hours. Assist the patient to the bedpan or commode. Make sure to check for output prior to flushing or disposing of the waste. If a bedpan is used, ensure to raise the head of the bed to a sitting position. Step 5 Step Five Assist the patient in cleaning of the anal area, take note of color, amount and consistency of the fecal matter, or liquid. Step 6 Step Six Lower the bed, raise side rails and place the patient in the position of comfort. Step 7 Step Seven Document all input and output, as well as color, size or amount, and any abnormalities. C O NT I NU E Assist with Continuous/Intermittent Bladder Irrigations Irrigation of the bladder is done to remove and flush out any blood, bacteria and waste products that may remain post-surgery. Continuous irrigation is performed after prostate or bladder surgery via the three-way, also known as foley, catheter system. The irrigation solution is hooked up to the irrigation part of the catheter. The solution container is hung onto the IV pole. Using the sterile technique, the solution is run throughout the tubing. This primes the tubing, removing any air. As we know, too much air can cause bladder damage, or bladder lining spasms. The tubing is then connected to the port of the catheter. Always consult the packaging for instructions when using the three-way catheter. Verify with the instructions, as well as provider’s orders for the appropriate flow rate. The return fluid should be light red to pink in color. Irrigation solution container must be changed every 24 hours. You will subtract the amount of irrigation fluid used from your output prior to documentation. There are two types of intermittent bladder irrigations; closed and open. Verify provider’s orders to determine which of the two you will need to complete. The process is listed below for both types of irrigations. Closed Intermittent Bladder Irrigations Verify and Educate the Patient Verify provider’s orders, verify patient Gather the following supplies: sterile irrigation set, basin, clean and sterile gloves, absorbent pad, antiseptic swabs, sterile normal saline or ordered irrigation solution, sterile 30 to 50 ml syringe with a sterile insertion connector, tubing clamp, bath blanket. Educate patient on the procedure. Set up work space. Close the room door, and or pull the curtains for privacy. Raise the bed to a comfortable working height. Perform hand hygiene and don gloves. Instruct patient to assume the dorsal recumbent position. Fan-fold the linen to expose the catheter. Use a bath blanket to cover the trunk of the body. Closed Intermittent Bladder Irrigations Check the Bladder Palpate the bladder for any distention. This ensures the fluid will not over distend the bladder. Closed Intermittent Bladder Irrigations Get Your Tools Set Open the sterile irrigation set. Place beside the patient’s thigh or between the legs. Ensure to maintain sterility to prevent any infection. Handling only the corners of the absorbent pad, place the pad under the catheter drainage tubing connection. Don sterile gloves. Closed Intermittent Bladder Irrigations Bladder Irrigation or Instillation Clamp the drainage tubing distal to the catheter connection. This directs the solution towards the bladder and prevents solution from draining into the collection bag. Measure amount of urine in drainage bag prior to irrigation. Closed Intermittent Bladder Irrigations Prepare the Irrigating Solution Using aseptic technique, pour 100-200 ml of irrigating solution into the sterile container. Verify amount from provider order, and local policy. While maintaining sterility, draw up approximately 30-40 ml of sterile solution into your syringe. Expel excess air from syringe and attach insertion catheter. Closed Intermittent Bladder Irrigations Attaching the Connector Before attaching the connector, scrub the port on the drainage tubing with an antiseptic swab. Attach the sterile connector into the port. Gently instill solution. Slow and steady. NOTE: Too much pressure can cause bladder spasms. Remove the insertion connector from the port. Cleanse the port with an antiseptic swab. Place the cap on the connector to maintain sterility. Closed Intermittent Bladder Irrigations Irrigation Immediately unclamp the tubing and lower the catheter to allow fluid to run into the drainage tubing. You must allow fluid and debris to flow out through the catheter. Closed Intermittent Bladder Irrigations Instillation Leave tubing clamped according to provider’s orders. Unclamp and allow fluid to drain into drainage container. Medicine must contact the bladder prior to draining. Closed Intermittent Bladder Irrigations Repeat Repeat process until: All of the order solution is used. Catheter is clear and bladder is draining clear urine. Closed Intermittent Bladder Irrigations Empty the Drainage Bag Empty the urine in the drainage bag. Measure output. Annotate the color and characteristics. Chart intake and output into patients chart. NOTE: Irrigation solution must be deducted from the total output. Closed Intermittent Bladder Irrigations Dispose of Supplies and Equipment Dispose of any supplies and equipment. Doff gloves. Make the patient comfortable, lower the bed, raise the side rails, place call bell within reach, ensure clamp is open. Perform hand hygiene. Closed Intermittent Bladder Irrigations Access and Document Assess the patient for discomfort. Document the following; date and time, irrigation method, amount and type of solution used, amount of solution used each time, appearance of return fluid, if the patient tolerated the procedure, and if the catheter is patent. The bladder Multiple Choice What are the types of intermittent bladder irrigations? Irrigation and Closed Open and Clutched Open and Closed Closed and Continuous SUBMIT Complete the content above before moving on. C O NT I NU E Open Irrigations Verify and Educate the Patient Verify provider’s orders, verify patient Gather the following supplies: sterile irrigation set, basin, clean and sterile gloves, absorbent pad, antiseptic swabs, sterile normal saline or ordered irrigation solution, sterile 30 to 50 ml syringe with a sterile insertion connector, tubing clamp, bath blanket. Educate patient on the procedure. Set up work space. Close the room door, and or pull the curtains for privacy. Raise the bed to a comfortable working height. Perform hand hygiene and don gloves. Instruct patient to assume the dorsal recumbent position. Fan-fold the linen to expose the catheter. Use a bath blanket to cover the trunk of the body. Open Irrigations Check the Bladder Palpate the bladder for any distention. This ensures the fluid will not over distend the bladder. Open Irrigations Get Your Tools Set Open the sterile irrigation set. Place beside the patient’s thigh or between the legs. Ensure to maintain sterility to prevent any infection. Handling only the corners of the absorbent pad, place the pad under the catheter drainage tubing connection. Don sterile gloves. Open Irrigations Bladder Irrigation or Instillation Clamp the drainage tubing distal to the catheter connection. This directs the solution towards the bladder and prevents solution from draining into the collection bag. Measure amount of urine in drainage bag prior to irrigation. Obtain sterile connector cap. Open Irrigations Disinfect Perform hand hygiene. Don sterile gloves. Disinfect the junction of the catheter and drainage tubing with an antiseptic swab. Place your fingers at least one inch from the junction, and separate the catheter and tubing. Place sterile tube cap over the drainage tubing end. Open Irrigations Attaching the Connector Draw up 30-40 ml of solution into your sterile irrigation system Carefully fit the tip into the catheter. Pressing the plunger, gently instill the solution into the catheter. Open Irrigations Removal Remove and disconnect the syringe. Allow the fluid to run from the catheter into the sterile drainage container. Repeat until the fluid is running freely or until the irrigation is complete. A clogged catheter may take multiple irrigations to unclog. Remove the cap on the drainage tubing and reattach it to the catheter. Ensure both ends remain sterile. Swab the connection with an antiseptic swab. Open Irrigations Discard and Document Discard supplies and equipment. Doff gloves and perform hand hygiene. Document procedure, subtracting solution from output. E ND O F L E S S O N