Enteral Nutrition and Tube types_Insertion.pdf

Enteral Nutrition General Information Also known as tube feeding Provides nutrients into the GI tract. It is a physiological, safe, and economical nutritional support Preferred over parenteral nutrition Many social, religious, and cultural even...

Enteral Nutrition General Information Also known as tube feeding Provides nutrients into the GI tract. It is a physiological, safe, and economical nutritional support Preferred over parenteral nutrition 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 Who should be fed this way? Clients who cannot eat ○ Neurological problems Clients who will not eat ○ Mental health/illnesses, geriatric, failure to thrive Clients who can’t maintain adequate nutrition ○ Cancer patients ○ Burn patients ○ NPO patients Formulas Variety of formulas: 3 main types Intact, Hydrolyzed and Modular ○ Special formulas for patients with diabetes, liver, kidney, and lung disease ○ Osmolarity, amount of protein, sodium, and fat vary Can cause dehydration because of very low water content. Can have an order for a free water flush Complications Vomiting (too much fluid/rate is too high) Dehydration ○ More calorically dense, less water formula ○ Check for high protein content Diarrhea Constipation Misconnection ○ Inadvertent connection between an enteral feeding system and non enteral feeding system ○ Severe patient injury or death can result Delivery Options Continuous infusion by pump Intermittent feedings for bolus by syringe Cyclic feedings by pump/gravity (8 hrs. at night, supplemental feeding) General Nursing Considerations Daily weights (1lb a week is expected) Assess for bowel sounds before feedings check every 4-6 hrs for placement Accurate I&O Label with date and time started Pump tubing changed every 24 hrs. Bottles changed every 34-48 hours Bags changed every 12-24 hours Check electrolyte levels (sodium, chloride, potassium ect.), glucose levels (every 6 hrs.), Albumin (nutritional standing), BUN (kidney function), Urine specific gravity, H&H (rises when dehydrated), WBC’s (infection) Tube feeding Administration Tube patency ○ Meticulous flushing of tube (tepid/room temp water) ○ Continuous feedings administered on feeding pump with occlusion alarm Feeding Considerations Patient Position ○ Check gastric residual volumes (by aspirating tube) Every 4 hours during Increase volume leads to aspiration ○ Promotility drugs may be ordered Tube position, secure correctly and make sure it is in the right place Patient should be sitting or lying with HOB at 30-45 degrees HOB remains elevated for 30-60 minutes for intermittent delivery Site care Assess the skin around tube daily Monitor bumper tension (G-tube/J-tubes) Apply a dressing only until site is healed After applied, wash with soap and water Protective ointment or skin barrier Gerontologic Considerations More vulnerable to complications ○ Fluid and electrolyte balances ○ Glucose intolerance ○ Decreased ability to handle large volumes ○ Increased risk of aspiration Pediatric Considerations Breast milk preferred over formula Continuous feeding must be delivered on infusion pump May be fed intermittent/bolus Smaller volumes of nutrition and flush Burp afterwards Medication Administration (Enteral Route) Liquid preparations are preferred Gravity method preferred Tablets must be crushed Capsules open/emptied Gel caps pierced/dissolved in warm water Not all medications can be crushed ○ SR (Sustained release) ○ ER or XL (extended release) ○ CR (controlled release) ○ EC (Enteric-coated) ○ LA (long-acting) Enteral/Gastric Tubes Two main purposes ○ Gavage-input ○ Decompression-output Major NG tube types ○ Large Bore Tube ○ Small Bore Tube Placement considerations/possible Contraindications Facial Trauma Esophageal Trauma Cranial Trauma Birth defects=cleft lip/palate (pediatrics) Coagulation abnormalities Esophageal Varices or Strictures Nasogastric Tube (NGT, NG Tube) Measured by french system: A system used to indicate the outer diameter of catheters (smaller number=small diameter) Short term use (feeding, decompressing or lavage) Neonates: 4-8 Fr Pediatrics: 6-14 Fr (21-39 inches in length)  Adults: 12-18 Fr (42-55 inches in length) Salem Sump Tube Large bore tube Ideal for decompression Can be used for feeding, but not intended purpose Levine Tube Ideal for short-term feeding Dobhoff Small bore tube Used primarily for feeding Has guidewire to aid in insertion Non-nasogastric Tubes Gastrostomy (AKA: Peg Tube, G-Tube) Jejunostomy Tube Principles for Practice Placement depends on.. ○ Purpose ○ Duration ○ Patient condition Complications Minor ○ Nasal Irritation ○ Epistaxis ○ Sinusitis Major/Placement related ○ Pneumothorax ○ Tracheobronchial aspiration ○ Pneumonia ○ Intracranial Intubation ○ Trauma (Nares, larynx, esophagus, mucosal lining) ○ Death Inserting a Nasogastric Tube Provider Order Labs Patient assessment Education Proper Equipment CXR post procedure NGT Insertion Steps Educate patient Abdominal assessment Inspect nares for patency Inspect oropharynx Gather supplies Position patient in High Fowlers Measure for NGT insertion length Prepare equipment Insert tube Secure tube Assess PH confirmation Send for X-ray confirmation Principles for Practice Radiographic Confirmation Note length of tube (exit point) Assess gastric pH (should be 5) Routine irrigation is recommended Keep HOB elevated 30 degrees or higher Recording and Reporting Record type and size of tube placed, location of distal tip of tube, patients tolerance of procedure, condition of nares, confirmation of tube position by x-ray film examination Record removal of tube and patients tolerance Report any type of unexpected outcome and the interventions performed Enteral Tube Removal Assess patient Educate Turn off suction/disconnect Inject tube with 20 mL air Remove tape from tube/nose Drape patient Have patient hold breath Remove tube steadily and smoothly Inspect nose and document Delegation and Collaboration Verification of tube placement cannot be delegated to NAP