Nutritional Therapy and Assisted Feeding PDF

chapter 27 Nutritional Therapy and Assisted Feeding http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 9. Identify the medical rationale and nursing care for a 1. Identify the nurse’s role related to nutritional...

chapter 27 Nutritional Therapy and Assisted Feeding http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 9. Identify the medical rationale and nursing care for a 1. Identify the nurse’s role related to nutritional therapy and patient receiving peripheral parenteral nutrition (PPN) and special dietary needs. total parenteral nutrition (TPN). 2. Compare and contrast a full liquid diet with a clear liquid 10. Understand the possible complications associated with diet. modiied diets, tube feedings, PPN, and TPN. 3. Explain the different dietary modiication levels: pureed, Clinical Practice 1. Using therapeutic communication, assist a patient who mechanically altered, advanced, and regular. 4. Describe health issues related to nutrition. requires a special diet. 5. List disease processes that may beneit from nutritional 2. Develop a patient education plan for nutritional therapy. therapy. 3. Demonstrate insertion, irrigation, and removal of a 6. Verbalize the rationale for assisted feedings and tube nasogastric tube. feedings. 4. Demonstrate feeding a patient through a nasogastric tube 7. List the steps for the procedure to insert, irrigate, and or percutaneous endoscopic gastrostomy (PEG) tube. remove a nasogastric tube. 5. Know your facility’s policies, procedures, and protocols 8. Discuss the procedure for tube feeding. for nutrition-related problems and complications with tube feedings. Skills & Steps Skills Skill Skill Skill Skill 27.1 27.2 27.3 27.4 Steps Assisting a Patient with Feeding 485 Inserting a Nasogastric Tube 497 Using a Feeding Pump 501 Administering a Nasogastric, Duodenal, or Percutaneous Endoscopic Gastrostomy Tube Feeding 502 Steps 27.1 Nasogastric Tube Irrigation 499 Steps 27.2 Nasogastric Tube Removal 500 Key Terms anorexia nervosa (ăn-ō-RĔK-sē-ă nĕr-VŌ-să, p. 488) atherosclerosis (ăth-ĕr-ō-sklĕ-RŌ-sĭs, p. 491) binge eating (p. 488) body mass index (BMI) (p. 489) bulimia nervosa (bū-LĒ-mē-ă, p. 488) diabetes mellitus (dī-ă-BĒ-tēz MĔL-ĭ-tĭs, p. 491) dysphagia (dĭs-FĀ-jē-ă, p. 495) enteral (ĔN-tĕr-ăl, p. 495) feeding pump (p. 501) gastrostomy tubes (găs-TRŌS-to-mē, p. 495) glycosuria (glī-kōs-ŬR-ē-ă, p. 504) heart failure (HF) (p. 491) homeostasis (hō-mē-ō-STĀ-sĭs, p. 487) hyperosmolality (HĪ-pĕr-ŎS-mō-LĂ-lĭ-tē, p. 504) 484 hypertension (p. 489) jejunostomy or duodenal tubes (jĕ-jūn-ĂW-stō-mē, dū-ăDĒ-năl, p. 495) myocardial infarction (MI) (p. 491) nasogastric (NG) tubes (nā-zō-GĂS-trĭk, p. 495) NPO (p. 487) parenteral (pă-RĔN-tĕr-ăl, p. 504) percutaneous endoscopic gastrostomy (PEG) tubes (pĕr-kū-TĀ-nē-ŭs găs-TRŎS-tō-mē, p. 495) peripheral parenteral nutrition (PPN) (pă-RĔN-tĕr-ăl, p. 504) postoperative (p. 487) preoperatively (prē-ŎP-ĕr-ă-tĭv-lē, p. 487) residue (p. 487) total parenteral nutrition (TPN) (pă-RĔN-tĕr-ăl, p. 504) Nutritional Therapy and Assisted Feeding CHAPTER 27 485 Concepts Covered in This Chapter • • • • • • • • • • • • • • • Acid base balance Care coordination Cellular regulation Clinical judgment Collaboration Communication Culture Health promotion Nutrition Elimination Fluid and electrolyte balance Glucose regulation Patient education Safety Tissue integrity THE GOALS OF NUTRITIONAL THERAPY The goals of nutritional therapy are to treat and manage disease, prevent complications, and restore or maintain health through appropriate diet. Patients in health care facilities have multiple dietary needs related to disease processes; surgical procedures; physical health; and cultural, religious, and individual preferences. The speciic diet for each patient is prescribed on the primary care provider’s order. Some patients may have diets without restrictions that are similar to meals eaten at home. For other patients, nutritional therapy is a signiicant factor in their medical treatment. You can assist patients in meeting their nutritional goals by completing thorough nutritional data collection. Monitor the patient’s food and luid intake and document the response to therapy. FIGURE 27.1 Assisting with feeding. Weight gain or loss, percentage of meals eaten, and ability to tolerate the diet should be included in the documentation. QSEN Considerations: Teamwork and Collaboration Nutritional Modification Modiication of the diet to increase the effectiveness of therapy can be accomplished through discussion with the patient, the primary care provider, and the registered dietitian. Collaboration with the patient is key. Patients who may need assistance with food and luid intake include those who have paralysis of the arms, visual impairment, intravenous lines or other devices in their hand or arm, problems breathing or swallowing (dysphagia), or severe impairments or weakness (Fig. 27.1). You may delegate this task to the nursing assistant or a family member, if appropriate (Skill 27.1). Skill 27.1 Assisting a Patient with Feeding Assisting a patient with feeding is a nursing responsibility. Patients with physical or mental impairment may require the expertise of a nurse to ensure that a safe feeding procedure is followed. SUPPLIES • Tray with dishes of food • Over-the-bed or tray table • Utensils • Napkin • Straw • Small towel or extra napkin (clothing protector) Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Assess patient’s need for assistance with feeding. (Guides type of assistance to be given.) Planning 2. Check the diet on the tray with the diet sheet. (Ensures that patient receives the correct diet.) 3. Clear the over-the-bed table and place the diet tray on it. Position patient in as high a Fowler 486 UNIT VI Meeting Basic Physiologic Needs position as is comfortable and permitted, or assist patient to a chair. Position the over-the-bed table with the diet tray on it in front of the patient. (Swallowing is enhanced by an upright position.) Step 7 Step 3 4. Protect patient’s clothing and bed linens with a towel, clothing protector, or napkin. (Protects clothing or bed linens from soiling if food is spilled.) Step 4 5. Open the containers of food, luids, condiments, and eating utensils. (Prepares food for feeding the patient.) Implementation 6. Ask which foods the patient prefers to begin with; alternate foods. Add condiments as desired by the patient. Offer small bites, and wait until the patient has chewed and swallowed before offering the next bite. (A relaxed, unhurried manner will encourage the patient to eat more of the meal.) 7. Offer luids when the patient desires. Place a lexible straw in the luid container and hold the container steady to allow the patient to grasp the straw with his lips. Be certain the liquid is not too hot. (Liquids help wash down food. Do not offer too much to drink because this will interfere with digestion. A straw masks the degree of heat in the luid, and patients may burn their mouths if the liquid is too hot.) 8. Wipe the mouth at intervals as needed. Talk with the patient during the meal. Do not appear rushed. (Removal of food particles from the sides of the mouth preserves the patient’s dignity. Conversation adds to the social atmosphere and can improve food intake.) 9. Encourage patients who are physically capable to feed themselves as much as possible. (Self-feeding increases self-esteem.) 10. Refrain from insisting that patient inish entire meal. (Gentle persuasion to take just another bite is appropriate for the patient who is taking a smaller amount of nutrients than required, but patient’s wishes must be respected.) 11. When the meal is inished, remove the tray; offer hand hygiene and oral hygiene. (The patient’s hands may have become soiled if the patient participated in feeding. Oral hygiene refreshes the mouth and removes retained food particles.) The Visually Impaired Patient 12. For the patient who is visually impaired but able to self-feed, describe what foods are on the plate and tray. Orient the patient to the position of the foods on the plate by describing the plate as if it is a clock face with particular foods positioned at: for example, 12:00, 3:00, 6:00, and 9:00. (Many patients who have their eyes bandaged or who are blind are still able to feed themselves if given adequate orientation to the plate and tray.) 13. Complete procedure as listed for the patient who needs assistance. (Patients with additional impairment may need nursing assistance for feeding.) Evaluation 14. Assess the patient’s tolerance of the meal, the amount consumed, and any dificulty experienced. (Provides information for modiication of diet if necessary.) Nutritional Therapy and Assisted Feeding CHAPTER 27 Documentation 15. Document the amount and type of food consumed during the feeding and patient’s response. (Documents nutritional intake and how it is tolerated. Communicates progress to the health care team.) Documentation Example 2/16 1200 Fed lunch; ate 50% of meal. Had dificulty chewing and swallowing meats. Occasional coughing when swallowing. Discussed with primary care provider. Diet changed to pureed meats. (Nurse’s electronic signature) THE POSTOPERATIVE PATIENT Patients scheduled for surgical procedures may have special nutritional needs. Ideally, the surgical patient should be well nourished preoperatively (before surgery) to facilitate postoperative (after surgery) healing and recovery. Preoperative patients usually placed on NPO (take no food or luids by mouth) status for up to 12 hours before the procedure. This practice decreases the risk of vomiting while under anesthesia, which could lead to aspiration of stomach contents. Aspiration can result in serious respiratory complications. Always check with the surgeon for exceptions to NPO orders. These exceptions may include diabetic, cardiac, and/or any other medications (with a “sip” of water) that ensure patient stability during surgery. Think Critically How does the anatomy of the gastrointestinal tract relate to the risk of aspiration when a patient is under anesthesia? Postoperative patients progress from a clear liquid diet to a full liquid diet. Solid foods are added when the patient can tolerate them without nausea, vomiting, or other abdominal discomfort. Clear liquids are started when the patient has a return of bowel sounds detected by auscultation. Clear liquids primarily maintain luid homeostasis and relieve thirst. The goal is to introduce luids that have low residue (remains after digestion), are easily digested, and have low risk of causing abdominal discomfort. Abdominal distress, such as vomiting and distention, can cause injury to surgical interventions. Foods that are clear luids at room temperature (e.g., gelatin and Popsicles) and liquids that are clear are included on the clear liquid diet. Some care providers restrict use of cola drinks on a clear liquid diet, but allow carbonated drinks that are clear, such as ginger ale. Clear liquid diets are used short term because the diet is deicient in most nutrients. Bouillon (broth) added to the diet provides small amounts of protein and some electrolytes. 487 Critical Thinking Questions 1. The patient requires assistance with feeding, but is reluctant to allow the nurse to help. Identify strategies the nurse might use to make the procedure more acceptable. 2. The patient is recovering from a stroke. Right-sided weakness is noted on assessment. What safety measures might the nurse use to reduce the risk of complications during assisted feeding? A full liquid diet may be used as a step between clear liquid and mechanical soft or regular diet. Full liquid is used following surgery, long-term fasting, or for those with chewing or swallowing problems. Full liquid diets include all luids, custards, ice cream, sherbet, puddings, and cooked reined cereals. Full liquids can be used for longer-term nutritional management because protein and other essential nutrients, vitamins, and minerals are available from the foods allowed. The full liquid diet is, however, low in iron, vitamin A, vitamin B12, and thiamine; therefore, vitamin and mineral supplements must be provided for longer-term use. Foods allowed in clear liquid diets and full liquid diets are compared in Box 27.1. Patients recovering from surgical procedures that involved manipulation of or surgical incision into the stomach or bowel may progress to a soft diet before attempting a general or regular diet. Soft diets are low in iber, and foods are softened by cooking, mashing, or chopping. Foods allowed on a soft diet include eggs; breads without seeds; boiled or mashed potatoes; soups; fruit; juices; tender cooked vegetables; meat that is stewed, boiled, or ground; cooked cereals; mashed bananas; applesauce; and milk products. As the patient’s condition progresses, the diet is advanced to general. This diet has no speciic restrictions unless required because of a patient’s speciic disease process. Think Critically Your patient is scheduled for a bowel resection. How would you discuss dietary goals with your preoperative patient? What would you include in the expected dietary progression and explanation to your patient? HEALTH ISSUES RELATED TO NUTRITION FEEDING AND EATING DISORDERS Feeding and eating disorders are comprised of categories of disorders that occur across the life span. In adolescence and young adulthood, individuals can develop conditions related to dietary intake. These are diagnosed as mental health disorders and include anorexia nervosa, bulimia nervosa, and binge eating. 488 UNIT VI Meeting Basic Physiologic Needs Box 27.1 Full Liquid and Clear Liquid Diets FOOD ALLOWED ON A CLEAR LIQUID DIET FOOD ALLOWED ON A FULL LIQUID DIET • • • • • • • • • • • • • • • • • • • • • • • Grape, apple, and cranberry juices Strained fruit juices Vegetable broth Carbonated water (preferably clear) Clear fruit-lavored drinks Sweetened gelatin and ices Clear candies Popsicles Tea or coffee Clear broth Anorexia Nervosa Anorexia nervosa is a psychological disorder characterized by restriction of caloric intake, a very low body weight for the developmental stage, a pathological fear of becoming fat, and a severe disturbance in body image. It is prevalent among adolescent and young women; however, adolescent and young men may also be affected. They view themselves as obese despite being extremely underweight. Patients with anorexia nervosa severely restrict caloric intake and focus on moderate to vigorous physical activity. If not corrected, anorexia nervosa can be fatal. Treatment is a combination of nutritional intervention, behavioral modiication, and psychological counseling. QSEN Considerations: Patient-Centered Care Considering Patient and Family Values Collaboration among the patient, family, primary care provider, mental health professional, nurse, and dietitian is crucial. A nutritional plan to be implemented should always be acceptable to the patient. The treatment goals are to plan and achieve a nutritious, healthy eating pattern and to attain a body weight that is at least 85% of expected weight for height. The patient must be willing to remain in psychological therapy and follow nutritional recommendations to achieve treatment success. Communication The Patient With Anorexia Nervosa Terri Mashburn is a 16-year-old high school junior admitted with a diagnosis of anorexia nervosa. Terri has lost 30 lb over the past 3 months because of extreme caloric restriction and excessive exercise. She is observed during all meals. You are assigned to sit with Terri during her lunch. Nurse: “Hello, Terri. Your lunch is here. I’m going to sit with you while you eat.” Terri: (Moves from chair to bed.) “You can take that away. I can’t eat that stuff! I’m not hungry anyway.” (Curls up in bed; hides face in pillow.) Milk and milk beverages Yogurt, eggnog, and pudding Custard and ice cream Pureed meats and vegetables in cream soups Strained fruit juices Vegetable juices Sweetened plain gelatin Cooked reined cereals Strained or blended gruel All other beverages Cream, margarine, and butter Sherbet Popsicles Nurse: (Places tray on table. Sits on bed next to Terri.) “You seem upset, Terri. Tell me what’s bothering you.” (Places hand on Terri’s shoulder.) Terri: “Nothing is bothering me. I just don’t want to eat.” Nurse: “Tell me about that.” Terri: “The nurse weighed me this morning. I’ve gained 2 lb since I’ve been here. This food is making me fat!” Nurse: “I know you are concerned about your weight. Let’s talk about the medical plan concerning your weight.” Terri: (Sits up in bed.) “OK, but you are not going to make me eat all that food.” Nurse: (Brings tray to beside.) “Tell me which foods you will eat. If you do not like any of them, I can get whatever you want from the dietary department.” Terri: (Raises cover on food.) “None of that will do. It will make me fat. I’ll eat a salad and an apple. Sprite to drink will be all right.” Nurse: “I will call dietary now.” (Calls dietary department to order food.) “Now, let’s review your medical plan while we wait.” Bulimia nervosa. Bulimia nervosa is an eating disorder characterized by episodic binge eating, followed by behaviors designed to prevent weight gain, including purging, fasting, using laxatives, and exercising excessively. Women with bulimia nervosa are aware of their problem and often feel ashamed of the behavior. Treatment of bulimia nervosa is usually easier because of this awareness. Psychological and nutritional counseling is necessary. The treatment plan may include nutritional supplements and monitoring of patients after eating to ensure purging does not occur. Medical conditions such as esophageal and peptic ulcers, depressed gag relex, and dental issues may accompany bulimia because of the gastric acid exposure during frequently induced vomiting. This condition must be treated with behavioral modiication to stop these practices. Binge eating disorders. Binge eating is deined as recurrent episodes of consuming signiicantly more food in a deined period of time than most people would Nutritional Therapy and Assisted Feeding CHAPTER 27 eat under similar circumstances. Binge eating disorder is one of the most common eating disorders; however, it often goes undiagnosed. Binge episodes are marked by feelings of lack of control. An individual with binge eating disorder may consume foods rather quickly and often do this when they are not hungry. Women are most often affected by this disorder. Many individuals experiencing binge eating generally hide their habit as it is characterized by feelings of guilt, embarrassment, or disgust (American Psychiatric Association, 2013). Clinical Cues The patient with a feeding and eating disorder requires careful observation and skilled therapeutic communication. You should observe the patient for evidence of “hoarding” food and structure communication to achieve compliance with the treatment regimen. Nursing interventions for patients with feeding and eating disorders include nutritional management, behavioral modiication, patient education, and monitoring progress. Patient education should include principles of healthy weight maintenance; components of a healthy diet; the dangers of fasting, purging, and binging; and the availability of community support groups. Nurses should document the patient’s weight, compliance with nutritional recommendations, and behaviors, as well as the effectiveness of the diet and need for modiication of any aspect of the treatment plan. OBESITY Obesity rates continue to rise, and obesity (excessive accumulation of body fat) has become a national health threat. The Centers for Disease Control and Prevention (2015) estimates that about 34.9%, or 78.6 million, of adult Americans are obese. Poor diet and limited physical activity are major factors contributing to the epidemic levels of overweight and obese Americans. Obesity is the second leading cause of preventable death in the United States. Many factors contribute to obesity, including genetics, environment, poor eating habits, lack of knowledge about good nutrition, medications, body physiology, age, and gender. Nutritional modiications and physical activity to manage obesity must be individualized and incorporate all factors relevant to the patient. It is well documented that obesity is responsible for putting people at risk for 30 chronic health conditions, including cardiovascular disease, stroke, diabetes, hypertension (abnormally elevated blood pressure), gallbladder disease, joint disease, and some forms of cancer. The goal of obesity treatment is to improve health and quality of life. Long-term success of weight management programs is low. Approximately 5% of obese people who reach their desired weight management goal can maintain their weight status over a 2- to 5-year period. Reaching a speciic weight status 489 should not be the only measure of success; a lifestyle change is key. Nutrition Considerations LET’S MOVE! The Let’s Move program was launched by Michelle Obama, the First Lady of the United States. The goal of this program is to eliminate childhood obesity within a generation. The program encourages the promotion of healthy families and healthier choices at home, to set everyone up for success. Recommendations include: • Eat ive fruits and vegetables each day • Have healthy choices available at home • Eat meals together as a family • Reduce snacks; offer fruits and vegetables when snacking • Be mindful of portion size • Reduce fat, sugar, and sugary drinks To accomplish weight loss, the individual must expend more energy than is consumed through intake of calories. Physical activity designed to match the patient’s ability is usually a component of weight management programs. Nutritional therapy depends on the patient’s degree of obesity. Obesity is characterized as mild to extreme. Obesity is determined using the body mass index (BMI) chart (see Chapter 26). The BMI is a mathematical calculation of height and weight; it may not be as reliable for individuals with very lean bodies or those who are pregnant or lactating. Excessive body fat is present in all instances of obesity. Obesity treatments include consultation and follow up with a health care provider, medically supervised special meal plans, medications (including appetite suppressants and nutrient absorption blockers), and surgical interventions. Effective nursing activities for weight reduction assistance include encouragement of low-calorie diets, plant-based or vegetarian diets, appropriate portion size, activity recommendations, and behavior modiication. The American Heart Association has diet and lifestyle recommendations for Americans (see Chapter 26). Bariatric surgery, which reduces stomach size and/ or reduces calorie and nutrient absorption, is currently touted as the most effective treatment to provide long lasting weight loss for people with extreme obesity (American Society for Metabolic and Bariatric Surgery, 2013); however, there are serious potential complications, even death. Very-low-calorie diets (500 calories/ day or less) are used only under close medical supervision because they can produce harmful complications. Nutrition Considerations BMI classifications Below 18.5—Underweight 18.5-24.9—Normal weight 24.5-29.9—Overweight 30 and greater—Obese 40 and greater—Morbid or extreme obesity 490 UNIT VI Meeting Basic Physiologic Needs Table 27.1 Recommendations for Total and Rate of Weight Gain During Pregnancy, by Prepregnancy Body Mass Index BMI+ (WHO) Less than 18.5 TOTAL WEIGHT GAIN RANGE (LB) 28-40 RATES OF WEIGHT GAINb 2ND AND 3RD TRIMESTER (MEAN RANGE IN LB/WK) 1 (1-1.3) Normal weight 18.5-24.9 25-35 1 (0.8-1) Overweight 25.0-29.9 15-25 0.6 (0.5-0.7) Obese (includes all classes) 30.0 and greater 11-20 0.5 (0.4-0.6) PREPREGNANCY Underweight BMIa (KG/M2) BMI, Body mass index. mass index is calculated as weight in kilograms divided by height in meters squared or as weight in pounds multiplied by 703, divided by height in inches. bCalculations assume a 0.5 to 2 kg (1.1 to 4.4 lbs) weight gain in the irst trimester. Modiied From Institute of Medicine (2009). Reprinted with permission from the National Academies Press. Copyright 2009, National Academy of Sciences. aBody Table 27.2 Changes in Nutrient Requirements During Pregnancy and Lactation MYPLATE GROUPSa PREGNANT WOMEN (SECOND HALF OF PREGNANCY) NONPREGNANT WOMEN LACTATING WOMEN MILKb Adult/Adolescent 3 or more cups/4 or more cups 3 or more cups/5 or more cups 4 or more cups/5 or more cups Citrus and other vitamin C foods 1 serving 2 servings 2-3 servings Dark green leafy or deeporange vegetable 1 serving at least every other day 1 serving daily 1-2 servings daily Other fruits or vegetables, including potatoesc 3-4 servings 2 servings 2 servings Meat or alternate protein 2 or more servings 3 or more servings (6 or more oz cooked) 3 or more servings (6 or more oz cooked) Cereal and bread, whole grains 6 or more servings 6 or more servings 6 or more servings Vegetable and fruit aAdditional servings of these or any other food may be added as needed to provide the necessary calories and palatability. Use iodized salt. Use water or other beverages—at least 6 to 8 cups daily. bIf fortiied milk is not used, obtain the primary care provider’s instructions for vitamin D supplementation. cTotal vegetable and fruit intake advised to be at least 4½ cups daily. Adapted from Peckenpaugh, N. J. (2011). Nutrition essentials and diet therapy (11th ed.). Philadelphia: Elsevier Saunders. PREGNANCY Nutritional status before and during pregnancy can inluence the health of the mother and the fetus. Nutritional data collection and counseling are important throughout the pregnancy to reduce the risk of complications such as low-birth-weight infants, gestational diabetes, and pregnancy-induced hypertension. Factors to consider when counseling a pregnant woman include her nutritional status before pregnancy, her age, the number of prior pregnancies, and her BMI at the onset of pregnancy. An increase in nutrients is needed for healthy growth of fetal and maternal tissues. Counseling should emphasize management of maternal weight gain and the taking of prenatal supplements, as prescribed. The guidelines for weight gain in pregnancy (Table 27.1) are more individualized because pregnant women now tend to be older and overweight or obese at the onset of pregnancy, and multiple pregnancies have become more common (American College of Obstetricians and Gynecologists, 2013, reafirmed 2015). Table 27.2 summarizes dietary needs during pregnancy and lactation. SUBSTANCE-RELATED AND ADDICTIVE DISORDERS Individuals who use alcohol, smoking, and other substances often present with nutritional deicits when entering health care facilities. Substance use interferes with food intake by decreasing appetite, decreasing inancial resources for food, and substituting calories in alcohol for calories in food. Substance use may also lead to impaired absorption and reduced storage and use of nutrients, along with increased metabolic needs. Patients with a history of substance use should be assessed for nutritional deicits. Thiamine deiciency is often present with alcohol use. Medical treatment usually includes luid and electrolyte supplements; vitamin and mineral supplements, especially thiamine; and a high calorie, high carbohydrate diet. Liver damage is common in patients with substance use because of the increased stress of metabolizing excessive alcohol and other substances. Dietary fat should be restricted if liver function is impaired. The nurse plays a vital role in evaluating nutritional status and the progress of treatment. Nutritional Therapy and Assisted Feeding CHAPTER 27 DISEASE PROCESSES THAT BENEFIT FROM NUTRITIONAL THERAPY CARDIOVASCULAR DISEASE Cardiovascular disease includes diseases of blood vessels, hypertension, myocardial infarction (MI) (loss of blood supply to the heart muscle), and heart failure (HF) (pump failure of the right or left ventricle). Nutritional therapy is focused on reduction of saturated and trans-fat, cholesterol, sodium intake, and red meats. Excessive saturated and trans-fat intake leads to development of atherosclerosis (accumulation of fatty deposits on the walls of blood vessels). This process narrows the vessel diameter, resulting in decreased blood supply throughout the body and speciically to the major organs. Narrow blood vessels increase the workload of the heart, resulting in hypertension as the heart attempts to circulate blood. Dietary management includes reduced intake of saturated fats (less than 7% of total calories), trans-fats (less than 1% of total calories), and cholesterol (less than 300 mg/day). The blood contains three types of cholesterol. Highdensity lipoprotein (HDL), known as “good cholesterol,” tends to cleanse vessels of fatty deposits. Low-density lipoprotein (LDL) increases fatty deposits on vessel walls. Very-low-density lipoprotein (VLDL) serves as a carrier for triglycerides in the blood (a type of fat linked to atherosclerosis and coronary artery disease); therefore, levels should be kept low. Consumption of trans-fats also increases levels of triglycerides. Increased levels of triglycerides can also signal a risk for diabetes or poor control of diabetes. Red meats, eggs, and high fat dairy products contain large amounts of saturated fat. Convenience foods, such as prepackaged or frozen foods, chips, and fast foods, usually have high levels of trans-fats. Consumption of low fat dairy products, vegetable oils, poultry, and ish is desirable to lower cholesterol levels. Recent research is suggesting that concentrated sugars may play a greater role in the development of heart disease than the consumption of saturated fats. Studies have linked a diet high in sugars to a 3-fold increase in death from cardiac disease, with fructose and sucrose posing the greatest risk (DiNicolantonio et al., 2016). Vitamin D may prevent cardiovascular disease, but three out of four Americans do not have adequate levels (30 to 40 ng/mL). How much vitamin D the body produces in response to sunlight exposure depends on many factors such as time of day (11 am to 3 pm is the best), time of year (summer is better), pigmentation in the skin (lighter skinned people produce it faster); yet it appears that 10 to 15 minutes of sunshine exposure is suficient to produce suficient vitamin D for people with lighter skin (National Health Service [NHS], 2013). Several studies identiied that calcium supplements with vitamin D decrease the inlammatory response, thereby decreasing the risk of cardiovascular disease (Carvalho & Sposito, 2015). Still, food is the best source of calcium (National Institutes of Health, 2013). Control of dietary sodium is also therapeutic in prevention and management of cardiovascular disease. 491 Large amounts of sodium cause luid retention. Increased luid volume in patients with HF increases the workload of the heart and results in increased respiratory distress and edema in the legs and feet. Increased luid volume and edema can also lead to hypertension. Research shows that Dietary Approaches to Stop Hypertension (DASH)— diets low in sodium and high in fruits, vegetables, nuts, seeds, legumes, and low-fat dairy products—can lower blood pressure even in healthy people (Mayo Clinic Staff, 2013). This might prevent hypertension later in life. The health care provider may prescribe a regular diet with no added salt, or sodium restriction from 250 mg to 4 g. Sodium content is concentrated in many foods, and limits can easily be exceeded. Teach and encourage patients to read food and beverage labels for sodium content and avoid adding salt to foods during cooking. Salt substitutes and no-salt seasonings may be used in cooking. Patients should consult with the primary care provider or dietitian before using salt substitutes because many contain ingredients that should be avoided by some people. Think Critically Do you know how much sodium you consume? Read the labels for sodium content of your favorite snack foods. Develop an awareness of the amount of salt you add to foods at the table or during meal preparation. DIABETES MELLITUS Diabetes mellitus is a disturbance of the metabolism of carbohydrates and other nutrients and the use of glucose by the body. There are two main types of diabetes. Type 1 diabetes, or T1DM, occurs when the beta cells of the pancreas stop secreting insulin. Insulin is needed to transport glucose across the cell wall. Type 1 diabetes usually develops at an early age. Type 2 diabetes, or T2DM, accounts for 90% to 95% of all cases of diabetes; it occurs when glucose receptors on the cell membrane lose their sensitivity to insulin. Insulin is secreted in normal or excessive amounts; however, the receptor sites do not allow most glucose to enter the cell. Although it used to appear primarily after age 40, type 2 diabetes is now appearing frequently in younger people; even children. The incidence of diabetes is increasing at an alarming rate in the United States. Of particular concern is the prevalence of type 2 diabetes among children, adolescents, and young adults. According to the American Diabetes Association (2014) African Americans, Mexican Americans, American Indians, Native Hawaiians, Paciic Islanders, and Asian Americans are at higher risk for T2DM, heart disease, and stroke. The goal of nutritional therapy for patients with diabetes is to control the amount of carbohydrates in the diet to maintain the blood glucose level at 70 to 120 mg/dL. The American Diabetes Association (ADA) does not endorse any one percentage of nutrients or any one meal plan for diabetes. The ADA does recommend a diet of moderate complex carbohydrates, including pasta, beans, whole grains, rice, and fruit. Patients should distribute carbohydrate intake 492 UNIT VI Meeting Basic Physiologic Needs Box 27.2 Dietary Strategies for Patients with Diabetes • Individualization: Arrange individualized medical nutritional therapy with a registered dietitian to tailor dietary strategies and goals for the person with diabetes. • Energy requirements: Match calories with physical activity; calories may be restricted if the person is overweight. • Variety: Eat a variety of foods, including fresh fruits and vegetables, complex carbohydrates, whole wheat pasta, legumes, whole grains, and brown rice. • Salt: Limit the amount of salt added to the diet. • Unusual physical activity: With T1DM, increase calories to meet increased metabolic demands. • Sick day plan: Maintain calorie intake and insulin dosages (for T1DM); the person may need to have small frequent feedings. • Travel: Continue the treatment plan regarding foods, medication, and blood glucose monitoring while away from home, and plan for the unexpected. • Eating out: Plan, determine appropriate choices beforehand, and modify the meals before and after the outing to ensure a balanced daily intake of carbohydrates. throughout the day and avoid ingestion of large amounts of carbohydrates at one meal. Complex carbohydrates usually contain more nutrients and higher iber content. Research suggests that iber delays the absorption of glucose, resulting in lower blood glucose levels. Dietary counseling related to reducing fat and sodium in the diet should be a part of the meal plan. People with diabetes are advised to reduce saturated fats to less than 10% of calories, minimize trans-fats, and restrict cholesterol to 300 mg/day (American Diabetes Association, 2015). A summary of general dietary strategies for patients with diabetes is provided in Box 27.2. Patients with diabetes are at higher risk for cardiovascular disease, hypertension, kidney disease, blindness, and stroke. Careful management of blood glucose levels can prevent or delay the onset of these complications. The nurse should encourage patients with diabetes to monitor their blood glucose closely, especially the effect of carbohydrate intake on blood levels. Individuals with diabetes should consult with and follow the dietary recommendations of a dietitian or nutritionist. Instruct patients in ways to include favorite foods into the diet and remain within their individual dietary plan. Develop the plan taking into consideration the type of diabetes, the patient’s activity level, and whether the patient is overweight. Every person with diabetes responds differently to carbohydrate intake. A serving of carbohydrates is 15 g regardless of the type of food. A patient can monitor his response to particular carbohydrates by measuring the blood glucose 1½ to 2 hours after eating. A blood glucose level of 180 mg/dL or below usually indicates an acceptable level following meals. Teach patients to read food labels to determine the amount of carbohydrates in a speciic food and include that food in the diet as part of the overall meal plan. A patient may consume simple carbohydrates such as ice cream or candy if they are included as part of the daily allowance of carbohydrates. Including these food items should depend on good diabetes control as determined by the health care provider. (Nursing Care Plan 27.1). Nursing Care Plan 27.1 Nutritional Therapy for a Patient with Type 2 Diabetes SCENARIO Teresa James is a 46-year-old African American diagnosed with type 2 diabetes 3 months before admission. She is an attorney in a busy law irm. She states she rarely has time to plan and prepare meals. “I just grab something on the run or eat out.” Mrs. James’s blood glucose level is 413 mg/dL on admission. She is 5′3″ and weighs 187 lb. PROBLEM/NURSING DIAGNOSIS Risk for unstable blood glucose level related to unwillingness or inability to make lifestyle adjustments. Supporting Assessment Data Subjective: Patient states, “I don’t have time for meal planning and preparation. I just grab something on the run or eat out.” Objective: Blood glucose 413 mg/dL. Weight 187 lb. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Patient will lose 2 lb by discharge date. Assess knowledge of disease process. Establishes knowledge base about disease process. Has weight loss occurred? Loses 2 lb by discharge date. Goal met. Assess willingness to Provides baseline data for make lifestyle changes. patient compliance. Patient’s blood glucose level will be below 130 mg/dL by second day of admission. Refer to dietitian for diet planning. Provides resource for component of needed lifestyle changes. Assess patient skill in measuring blood glucose. Establishes patient’s ability to Has blood glucose dropped? complete skill. Blood glucose 128 mg/ dL by second day of admission. Patient must monitor blood Outcome achieved. glucose to assess diabetes control and response to carbohydrates in diet. Provide instruction as needed. Nutritional Therapy and Assisted Feeding CHAPTER 27 493 Nursing Care Plan 27.1 Nutritional Therapy for a Patient with Type 2 Diabetes—cont’d Goals/Expected Outcomes Nursing Interventions Selected Rationale Patient will verbalize understand- Teach about medications, Encourages patient compliing of relationship of medicatheir use, administraance with dietary and tions to diet. tion, and side effects. pharmacotherapeutic Teach signs and sympmanagement of disease toms of hypoglycemia process. and hyperglycemia. Teach interventions for episodes of hypoglycemia and hyperglycemia. Evaluation Does patient understand about medication and diet? Verbalizes relationship of medications to diet. Outcome achieved. PROBLEM/NURSING DIAGNOSIS Acknowledges inability to make appropriate food choices/Risk-prone health behavior related to meal planning for diabetes; relationship of diet to management of disease. Supporting Assessment Data Subjective: Patient states, “I don’t have time for meal planning and preparation. I just grab something on the run or eat out.” Objective: Blood glucose 413 mg/dL. Weight 187 lb. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Patient will demonstrate ability to choose appropriately from a variety of fast-food and restaurant menus. Provide variety of fastfood and restaurant menus. Provides patient with lexibility in meal planning. Promotes understanding of carbohydrate counting. Does patient choose appropriate foods? Demonstrates ability to choose appropriate foods from fast-food and restaurant menus. Outcome achieved. Patient will demonstrate ability to develop a 24-h meal plan. Provide a list of a variety Demonstrates patient’s unof foods to compile derstanding of meal plan. menu. Can patient develop a 24-h meal plan? Demonstrates development of a 24-h meal plan. Outcome achieved. Patient will verbalize a weight management plan. Advise of proper weight. Weight management is a critical component in control of disease process. Has patient developed a weight loss plan? Verbalizes she will begin an exercise program to assist with weight management. Progressing toward outcome. CRITICAL THINKING QUESTIONS 1. You are asked to provide a list of dietary recommendations to a patient with diabetes. What will you include in the list? 2. Your patient states that she does not understand how to use the American Diabetes Association carbohydrate counting. Briely describe the use of the carbohydrate counting and its implications for the diabetic patient. Think Critically Do you have a close family member who has diabetes? Genetics play an important role in the development of T2DM. What steps can you take to prevent the onset of T2DM? HIV/AIDS Human immunodeiciency virus (HIV) and acquired immunodeiciency syndrome (AIDS) are associated with severe diarrhea, profound weight loss, and muscle wasting. Some patients lose as much as 50% of their body weight because of treatment, multiple infections, loss of appetite, malignancies, and gastrointestinal disorders. Nutritional therapy is directed toward replacing luids and electrolytes, fostering weight gain, replacing muscle mass through protein intake, and maintaining the strength of the immune system. Patients should be referred to the dietitian as soon as they are diagnosed as HIV positive. An older research study suggested the multivitamin supplements might delay the onset of full-blown AIDS (Fawzi et al., 2004). A more recent study demonstrated beneits of vitamins B, C, and E in delaying disease progression in pediatric AIDS patients (Zgambo et al., 2012). Although more research is needed, good nutrition is important for the patient living with HIV/AIDS. 494 UNIT VI Meeting Basic Physiologic Needs Calorie intake should be increased for patients with HIV/AIDS, with emphasis on protein intake. Infections, an impaired immune system, and medical treatment may result in painful lesions in the mouth and ulcerations in the esophagus and stomach. Solid food may be dificult to eat. Offer milkshakes with added calories and supplements such as Ensure Plus or Boost Plus to provide calories and protein. Fluids and electrolytes are best replaced orally, but per medical orders, may be replaced intravenously. Dietary considerations include: • Maintaining high calorie intake • Increasing protein intake to maintain or increase muscle mass • Offering bland, soft, or pureed foods when the mouth is painful • Adding thickening agents to liquids if indicated by the swallowing evaluation • Adding seasonings to help food taste more appealing • Encouraging small, frequent meals Table 27.3 Note: If thickening agents are used, assess for adequate hydration, because research has shown they may lead to inadequate luid intake. Complete assessment of health and nutritional status is important for patients diagnosed with HIV/AIDS. Typical nursing diagnoses for HIV/AIDS patients are: • Impaired oral mucous membrane related to altered immune system • Imbalanced nutrition: less than body requirements related to anorexia and oral lesions • Deicient luid volume related to prolonged diarrhea and decreased luid intake Table 27.3 provides a summary of nutritional recommendations for diseases and disorders of various body systems. ASSISTED FEEDING Patients who have high care needs, malnutrition, cardiovascular or nervous system disorders, or dementia may be unable to tolerate oral luid and food intake. Nutritional Therapy for Specific Diseases and Disorders CONDITION Gastroesophageal relux disease (GERD): Relux of gastric contents into the esophagus, causing irritation NUTRITIONAL THERAPY Assess foods that are best or least tolerated. Decrease alcohol, chocolate, and fat intake. Avoid cigarette smoking. Increase protein intake for healing. Lose weight if appropriate. Peptic ulcer: loss of tissues lining the esophagus, stomach, and duodenum Increase iron in the diet because of blood loss from ulcers. Increase protein and vitamin C. Avoid snacks that stimulate gastric acid. Eat small, frequent meals. Avoid medications that irritate the mucosa (e.g., aspirin or ibuprofen). Dumping syndrome: nausea, weakness, sweating, palpitations, and diarrhea, occurring after a patient has had a gastrectomy Eat small, frequent meals. Decrease intake of simple carbohydrates. Drink luids 45-60 min before or after meals. Lie down for 15-20 min after meals to decrease dumping. Inlammatory bowel disease: inlammation of the bowel causing malabsorption of nutrients (e.g., Crohn disease or ulcerative colitis) Avoid foods that cause symptoms. May be NPO for bowel rest; TPN in severe cases. High calorie, high protein, low fat, low iber, lactose-restricted diet. Diverticulosis or diverticulitis: formation of small sacs protruding through the bowel wall Clear liquid diet during acute phase. Progress to a high iber diet. Management: Avoid nuts, seeds, and foods with skin or undigested particles. Liver disease: cirrhosis and hepatitis Document intake and output. High protein diet to increase lean mass; restrict protein in advanced stages. High calorie diet for energy. Fat-restricted diet. Nutritional supplements. Avoid foods that irritate the esophagus because of esophageal varices. NPO during the acute phase. Nausea and vomiting Avoid food during the acute phases of nausea and vomiting. Limit foods to bland, low fat choices when they can be tolerated (e.g., dry toast and crackers). Clear liquids in small amounts. Eat small, frequent meals. Nutritional Therapy and Assisted Feeding CHAPTER 27 Table 27.3 495 Nutritional Therapy for Specific Diseases and Disorders—cont’d CONDITION Kidney failure NUTRITIONAL THERAPY High calorie, high carbohydrate, low protein diet. Control sodium, potassium, and phosphorus in the diet. Renal calculi Calcium- or oxalate-restricted diets may be ordered (restrict legumes, nuts, dark green leafy vegetables, and citrus fruits). Modiied calcium restriction may be ordered. High luid intake is usually indicated. Celiac disease Avoid wheat, barley, rye, and triticale (wheat–rye cross) products. Carefully scrutinize processed foods ingredient list for gluten. Avoid sharing utensils when preparing food. GERD, Gastroesophageal relux disease; NPO, no food or luids by mouth; TPN, total parenteral nutrition. One in ive older adults residing in long-term care facilities may experience dysphagia (dificulty swallowing) (van der Maarel-Wierink et al., 2015). Some patients may show common signs of swallowing problems such as coughing when drinking, drooling, or having food remaining in the mouth. A physician and a speech-language pathologist may conduct a formal swallowing evaluation and develop a management plan. More than half of patients who aspirate show no obvious signs or symptoms such as coughing (Macht et al., 2013). The aspiration may cause a voice change or feeling of food being stuck in the throat. For these patients, it is important to match dietary modiications to the patient’s swallowing, motor, and cognitive ability. Liquids can be thickened to help prevent aspiration. Solids can be ordered at four different texture levels: level I, pureed (pudding texture); level II, mechanically altered (moist and minced to ¼ inch maximum); level III, advanced (moist and bite sized; no hard or crunchy foods); and level IV, regular (all foods). Some patients recover and advance to level IV, whereas others may progress in their aging or disease process and may no longer tolerate oral intake of any kind. Once this happens, a feeding tube can be considered. NASOGASTRIC AND ENTERAL TUBES There are several types of enteral tubes. Tubes may be placed through the nose into the stomach (nasogastric tubes [NG] tubes), placed directly into the stomach (gastrostomy tubes or percutaneous endoscopic gastrostomy [PEG] tubes), or placed into the intestine (jejunostomy or duodenal tubes) (Fig. 27.2). Nasogastric tube placement is usually a temporary measure to provide nutritional support. The tube is placed through the nose and esophagus into the stomach. The NG tube may be used for other purposes, such as (Fig. 27.3): • Stomach decompression, such as removing stomach contents before or after surgery • Obtaining laboratory specimens • Gastric lavage for patients with gastrointestinal bleeding or for removal of ingested toxins • Medication administration (see Chapter 34, Skill 34.4) Safety Alert Tubing Misconnections The Joint Commission has issued several Sentinel Event Alerts involving tubing misconnection, including NG infusions inadvertently connected to IV tubing, and vice versa. Patient death has resulted from tubing misconnections. Luer-Lok connectors can cause many of these issues because they allow functionally dissimilar tubes to be connected. Always follow your facility’s policies. When enteral (intestinally absorbed) nutrition is needed over an extended time, small-bore feeding tubes (8 to 10 Fr.) may be inserted. Small-bore tubes are soft, lexible tubes that must be inserted by a skilled person using a guidewire or stylet. Active patients may ind the tube restrictive and inconvenient. Nursing care of patients with NG tubes involves insertion, irrigation, administration of tube feeding, checks for placement, checks for residual volume, and removal of the tube. Success in inserting the tube is more likely if the patient’s conidence is gained irst. Tube insertion is more dificult if the patient is unable to cooperate, such as patients who are unconscious or have impaired cognitive function (Skill 27.2). Explain the procedure and its beneit to the patient before beginning insertion. Proper placement of small-bore tubes must be veriied by x-ray examination. A tube that is not correctly positioned or poor body position can cause aspiration. Elevate the head of the bed for 30 to 60 minutes after a feeding to ensure residual volume is not aspirated. QSEN Considerations: Safety Check Tube Placement and Residual Volume Check tube placement and residual volume before feeding or administering medications, returning residuals per your facilities policies. Patients with decreased level of consciousness or a decreased cough or gag relex may not exhibit expected symptoms if the tube is displaced into the respiratory tract. Placement of the tube in the respiratory tract can lead to severe respiratory complications if misplacement is not detected before feeding or medication administration. 496 UNIT VI Meeting Basic Physiologic Needs Nasogastric tube Duodenal tube Feeding bag Pump Gastrostomy tube Jejunostomy tube FIGURE 27.2 Anatomic locations for nasogastric, duodenal, gastrostomy, and jejunostomy tubes. Levin tube Weighted feeding tube Salem sump tube FIGURE 27.3 Nasogastric and enteral feeding tubes. Monitor NG tubes frequently. Irrigate the NG tube with 30 to 60 mL of sterile water solution to ensure it is patent. Count the amount used for irrigation as part of the recorded intake (Steps 27.1, p. 499). Monitor for complications such as constipation, nausea, diarrhea, hyperglycemia, and electrolyte imbalances. When therapy is completed or the patient is able to tolerate oral feedings, remove the NG tube (Steps 27.2, p. 500. PERCUTANEOUS ENDOSCOPIC GASTROSTOMY OR JEJUNOSTOMY TUBES A PEG or PEJ tube is used when a patient requires long-term nutritional support and cannot take oral nutrition. The PEG/J tube has replaced surgical gastrostomy tube placement in most situations. The tube is placed via endoscopy. The PEG/J tube allows patients more freedom of ambulation and allows the patient to administer his own feeding easily. A PEG/J tube can be removed easily when it is no longer indicated. Care of the PEG/J tube is similar to that of the NG tube. Check tube placement at least every shift and before feeding or administering medication. Check the medical record for the placement measurements. Measure the tube length from skin level to the end of the placement adapter; compare the measurements. Higher measurements indicate the tube has migrated outward. If the tube becomes dislodged, notify the charge Nutritional Therapy and Assisted Feeding CHAPTER 27 497 Skill 27.2 Inserting a Nasogastric Tube A nasogastric (NG) tube is inserted per a care provider’s order, and is used with suction when a patient is experiencing excessive vomiting, needs stomach decompression after intestinal surgery, or is at risk for aspirating stomach contents because of decreased level of consciousness. If the patient needs enteral feedings, the tube is either attached to a feeding pump or left unattached and plugged off for intermittent feedings. SUPPLIES • Emesis basin • Stethoscope • Gloves • Drape or towel • Tongue blade • Measuring tape • NG tube • Flashlight • Glass of water, straw • Tape • Water-soluble lubricant • Plug for tube • Irrigation syringe and solution container • Safety pin • Tissues, paper towel • Sterile water solution • pH indicator strip (scale 1 to 11) • Wall suction or suction machine and connecting tubing, or feeding pump and tubing on a hand signal that will instruct you to stop if the patient experiences too much discomfort. (Basin will catch emesis if patient vomits. The signal allows the patient some control of the procedure.) 5. Don gloves. (Barrier protection is needed in case patient vomits or there is spillage of gastric contents.) 6. Measure the distance the tube is to be inserted by measuring from the tip of the nose to the tip of the ear and then to the xiphoid process. Mark the distance on the tube with a piece of tape. (Some tubes have approximate target markings on them: one black band indicating the length of the tubing needed to reach the stomach, two bands for the pylorus, and three bands for the duodenum. Marking the tube after measurement individualizes the tube length.) Nose Ear Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Assess patient’s understanding of procedure. (Patients can be more cooperative when they understand what is happening to them.) Planning 2. Check airlow through the nostrils: close one side of the nose, and check airlow through the other. (Determines which nostril is most patent and should be used for tube’s passageway.) 3. Gather all equipment needed. Position patient with the head of the bed elevated 30 to 90 degrees. Raise head of bed to working height. (Demonstrates good time management. Elevating head of the bed enables the tube to move by gravity down the digestive tract.) 4. Hand the emesis basin and the tissues to the patient. Otherwise, place emesis basin close beside the patient’s face with the tissues near the pillow. Agree Xiphoid process Step 6 7. Chill or warm the tube to desired stiffness for insertion. (A too limp or too stiff tube is dificult to insert. Placing a soft rubber tube in a basin of ice will stiffen it; placing a stiff plastic tube in a basin of warm water will soften it.) Implementation 8. Lubricate the tip of the tube and insert it through the nostril with the best airlow. If changing the NG tube, insert it in the nostril other than the one previously used to avoid further irritation of the tissue. With patient’s head hyperextended, aim the tube down and toward the ear. Twist tube slightly as you advance it. If you encounter severe resistance, withdraw the tube and insert in the other nostril. Do 498 9. 10. 11. 12. 13. UNIT VI Meeting Basic Physiologic Needs not forcibly push it because you could injure tissue and cause bleeding. (Using the largest passageway for insertion of the tube decreases tissue trauma. For easier insertion, use water or a water-soluble lubricant to moisten the tip of the tube. Do not use an oil-based lubricant because of the possibility of lipid aspiration.) As the tube reaches the back of the throat, have patient take sips of water through the straw, drop the head forward, and begin to swallow. (Offer encouragement by saying, “swallow, swallow,” when advancing the tube.) Check the position of the tube as it passes down the back of patient’s throat by having the patient open his mouth and hold down the tongue with a tongue depressor. If the tube is coiled up in the mouth, withdraw it into the nose and begin again by having the patient bend head forward and swallow. The patient can signal you to stop for a moment to rest, if necessary, but avoid waiting too long. (Dificulty with the tube entering the esophageal opening sometimes occurs.) Advance the tube each time the patient swallows. (The tube advances more easily with the assistance of esophageal peristalsis.) Check the placement of the tube: a. If ordered, an x-ray should be obtained. (X-ray conirmation is considered the “gold standard.”) b. pH testing: use the irrigating syringe to pull back, using gentle suction, and aspirate stomach contents. If no aspirate can be obtained, gently instill 10 to 20 mL of air then attempt to reaspirate. Test the pH of the aspirate, using the pH strips by comparing the color of the strip to the color chart on the bottle (Boeykens et al., 2014). (When the target point on the tube has reached the nose, the tube should be in the stomach; this can be veriied by checking the pH of the aspirated luid. Gastric pH is 1 to 4; intestinal and respiratory pH values are above 6. A pH value above 6 indicates possible tracheobronchial tube placement, and the primary care provider should be notiied.) c. Observe for changes in the volume and appearance of feeding tube aspirate (Gastric aspirates are typically grassy green or colorless; intestinal aspirates may be bile or yellow colored; respiratory aspirates are usually tan or off-white and mucoid.) Tape the tube securely to the face. Clean the bridge of the nose with a prep pad or apply tincture of benzoin to it. Cut a 4-inch long piece of 1-inch tape; split it up the middle for 3 inches. Place the solid piece of tape on the bridge of the nose, and spiral the split ends down the tube. Secure the tape with one more piece across the bridge of the nose. Be certain the tube is not rubbing the side of the naris because it can cause necrosis. (The tube must be secured so that it is not easily dislodged. Commercially made NG tube holders are available and may be used in your facility.) Step 13 14. Measure the tube from the insertion point at the nare, to the end of the tube. Document the length. (This assists with verifying placement and can determine if the tube has migra