STUDY GUIDE FOR EXAM 3.docx

[STUDY GUIDE FOR EXAM 3] [NUTRITION AND FLUID, ELECTROLYTE AND ACID BALANCE] [CHAPTER 42] Acidosis Alkalosis Anion Gap Buffers Extracellular fluid Extracellular volume Extracellular volume excess Extracellular volume deficit Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia Hypernat...

[STUDY GUIDE FOR EXAM 3] [NUTRITION AND FLUID, ELECTROLYTE AND ACID BALANCE] [CHAPTER 42] Acidosis Alkalosis Anion Gap Buffers Extracellular fluid Extracellular volume Extracellular volume excess Extracellular volume deficit Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia Hypernatremia Hyponatremia Hypertonic Hypotonic Isotonic Hypomagnesemia Hypermagnesemia Hypovolemia Hypervolemia Interstitial Fluid Intracellular Fluid Intravascular Fluid Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Osmolality Osmosis Filtration Osmotic pressure Oliguria- decreased urine output or end stage renal disease **[Fluid and Electrolyte or Acid-Base Imbalances]** Adult Male- 60% body weight is water Older Adult Male-50% body weight is water (decreases with age) **[Body fluid-]** Is located in 2 distinct compartments - Extracellular fluid (ECF) outside of cells - Intracellular fluid (ICF) located inside cells **[ECF]**- Has 2 Major Divisions - Intravascular Fluid- (liquid part of blood) - Interstitial Fluid- (located between cells outside of the blood vessels) **[Transcellular Fluid-]** Are secreted by epithelial cells - Cerebral Spinal Fluid - Pleural - Peritoneal - Synovial **[Composition of Body Fluids-]** Compounds that separate into ions (charged particles) **[Positively charged ions are called cations]** - Sodium (Na+) - Potassium (K+) - Calcium (Ca+) - Magnesium (Mg 2+) - Chloride (Cl-) - Bicarbonate (HCO 3-) BOTH ANIONS AND CATIONS COMBINE TO MAKE SALT **[Normal Lab Values]** - Osmolality- 285-295 **[Electrolytes]** - Sodium (Na+)- 136-145 - Potassium (K+)- 3.5-5.0 - Chloride (Cl-)- 98-106 - Total CO2- 23-30 - Bicarbonate (HCO3-)21-28 - Total Calcium (Ca2+)-9.0-10.5 - Ionized Calcium (Ca2+)-4.5-5.6 - Magnesium (Mg2+)- 1.3-2.1 - Phospate-3.0-4.5 - Anion Gap-6+/-4 mEq/L **[ABG'S Arterial Blood Gases]** - pH-7.35 to 7.45 - PaCO2- 35 to 45 - PaO2-80-100 - HCO3- 21 to 28 - O2 Saturation- 95% to 100% - Base Excess -2 to +2 mmEq/L **[Fluid-]**Contains a large number of dissolved particles is more concentrated than the same amount of fluid that contains only a few particles **[Osmolality-]** Number of particles in per kg of water, (Na+) does not pass easily through the cell membrane. Particles that cannot cross the cell membranes easily determine the tonicity (effective concentration) of a fluid. **[Isotonic-]**Fluid with the same tonicity of blood, cells are normal **[Hypotonic-]** (Remember Hippo) is more dilute than blood, cells enlarge **[Hypertonic-]**(Remember Hyper/Active) is less dilute, more concentrated, cells shrink Diagram of cell membrane and cell shrinks Description automatically generated with medium confidence **[MOVEMENT OF WATER AND ELECTROLYTES]** **[Active Transport-]**Requires energy in the form of ATP to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration) **[Diffusion-]**Passive movement of electrolytes or other particles down a concentration gradient (from areas of higher concentration to areas of lower concentration) with diffusion of electrolytes across the cell membranes it requires proteins that serve as ion channels. **[Osmosis-]**A process by with water moves through a membrane that separates fluids with different particles of concentration (water moves across the membrane) if particle concentration in interstitial compartment changes osmosis occurs. **[Filtration-]**Fluid moving into and out of the capillaries (between the vascular & interstitial compartments) The net effect of forces (4 of them) (2 of them move fluid out of the capillaries)(2 of them move fluid back into the capillaries) **[Hydrostatic pressure-]**is the force of fluid pressing outward against a surface.  A diagram of a blood vessel Description automatically generated **[Colloid-]** is albumin and other proteins in the blood. A Colloid is a larger particle that stay in the blood stream, they are to large to pass through the capillaries, colloids exsert osmotic pressure. **[Osmotic Pressure or Oncotic Pressure-]**Is the inward pulling force caused by blood proteins that helps move fluid from the interstitial area back into the capillaries. **[Edema-]**a collection of fluid that remains in the interstitial space. - Heart Failure (HF) - Congestive Heart Failure (CHF) **[FLUID BALANCE]** Fluid homeostasis consists of 3 processes - Fluid intake and absorption - Fluid Distribution - Fluid Output To maintain this balance input must be the same as output. Sometimes we lose fluid through sweat and hypotonic solution, we must stay hydrated. We can also achieve fluid intake through IV, rectal enemas, and irrigation of body cavities during surgery. **[AVERAGE FLUID INTAKE AND OUTPUT]** Normal (per Day) Prolonged Heavy **Fluid Intake** +-----------------------+-----------------------+-----------------------+ | Fluids ingested, oral | 1100--1400 mL | 280--1100 mL/hr | | | | | | Foods | 800--1000 mL | Highly variable | | | | | | Metabolism | 300 mL | 16--50 mL/hr | | | | | | ***Total*** | ***2200--2700 mL*** | ***300--1150 mL/hr*** | | | | | | **Fluid Output** | 500--600 mL | 300--2100 mL/hr | | | | | | Skin (insensible and | 400 mL | 20 mL/h | | sweat) | | | | | 100--200 mL | Negligible, unless | | Insensible lungs | | diarrhea during | | | 1200--1500 mL | exercise | | Gastrointestinal | | | | | ***2200--2700 mL*** | 20--1000 mL/hr, | | Urine | | depending on | | | | hydration status | | ***Total*** | | | | | | ***340--3120 mL/hr*** | +=======================+=======================+=======================+ | | | Rehydration with | | | | Na+-containing fluid | | | | necessary after | | | | prolonged vigorous | | | | exercise | +-----------------------+-----------------------+-----------------------+ **[Thirst-]**Is a conscious desire for water and is an important regulator of fluid intake when plasma osmolality increases or blood volume decreases. - Thirst control mechanism is located in the hypothalamus in the brain. Osmoreceptors continually monitor plasma osmolality; where increased, they cause stimulations of the neurons in the hypothalamus. This causes issues for people who cannot communicate thirst, (infants, patients with neurological disorders, psychosocial problems, and some older adults)  **[Fluid Distribution-]**Refers to the movement of fluid among its various compartments - Distribution between extracellular and intracellular (Osmosis) - Distribution between vascular and interstitial parts of the ECF (Filtration) **[Fluid Output-]**4 organs contribute to fluid output 1. Skin 2. Lungs 3. GI tract 4. Kidneys **[Abnormal Output-]**several factors are involved with abnormal output 1. Vomiting 2. Wound drainage 3. Hemorrhage 4. Fever 5. Burn to skin 6. Diarrhea **[Normal Output-]**How our bodies regularly excrete fluid from our bodies *Insensible (not visible)* 1. Skin-Continuous 2. Lungs-Continuous 1. Sweat 2. GI Tract 3. Feces NOTE: When a person loses more fluid in their output than they take in- an adjustment takes place/primarily caused by antidiuretics (ADH), the renin angiotensin aldosterone system (RAAS) and atrial natriuretic peptides (ANP) Diagram of a diagram showing the internal organs of a human heart Description automatically generated **[Antidiuretic Hormone (ADH)]** Regulates the osmolality of body fluid by influencing how much water is excreted in the urine. 1. Synthesized by neurons in the hypothalamus that release it from the pituitary gland 2. It circulates in the blood and kidneys where it acts on collecting ducts 3. It causes renal cells to reabsorb water, while diluting the blood by adding water. **[Factors that increase (ADH)]** - Severely decreased blood volume - Pain - Stressors - Medication **[Factors that decrease (ADH)]** - Levels become too dilute **[Renin -- angiotensin- aldosterone system (RAAS)]** Regulates ECF volume by influencing how much sodium and water are excreted in the urine. It also contributes to the regulation of blood pressure. - Special cells release renin in the kidneys - Renin converts to angiotensinogen to angiotensin I - Angiotensin I convert to angiotensin II by way of other enzymes in the lung capillaries - Angiotensin II is a vasoconstrictor in some vascular beds - Fluid homeostasis function of angiotensin II stimulate aldosterone which releases from the adrenal cortex - Aldosterone circulates to the kidneys - It reabsorbs sodium and water in the distal renal tubules - Renal tubules remove sodium and water and return it to the blood and it increases the volume of ECF. - Aldosterone also contributes to electrolyte and acid base balance, by increasing urinary excretion of potassium and hydrogen ions. - Certain stimuli can increase or decrease activity - Hemorrhage decreases ECV - Vomiting When blood flow is decreased more renin is released this increase of sodium and water retention is helping to restore ECV. **[Arterial Natriuretic Peptide (ANP)]** Regulates ECV by influencing how much sodium and water are excreted in the urine. Cells in the atria of the heart release ANP when they are stretched. **[Factors affecting ANP]** - Medication - Diarrhea - Alcohol - Sweat - Fever - Trauma/blood loss - Not drinking enough liquids - Vomiting - Disease 2 Major types of fluid imbalance are - Volume imbalance - Osmolality imbalance **[Volume Imbalance-]**The amount of fluid in the extracellular compartment. **[Osmolality Imbalance-]**Disturbances of the concentration of body fluids NOTE: Both volume and osmolality imbalance can occur separately or together.  **[FLUID IMBALANCES]** +-----------------------------------+-----------------------------------+ | Imbalance and Related Causes | | | Signs and Symptoms | | +===================================+===================================+ | Isotonic Imbalances---Water and | | | Sodium Lost or Gained in Equal or | | | Isotonic Proportions | | +-----------------------------------+-----------------------------------+ | **Extracellular Fluid Volume | | | Deficit---Body Fluids Have | | | Decreased Volume but Normal | | | Osmolality** | | +-----------------------------------+-----------------------------------+ | ***Sodium and Water Intake Less | ***Physical examination:*** | | Than Output, Causing Isotonic | Sudden weight loss (overnight), | | Loss:*** | postural hypotension, | | | tachycardia, thready pulse, dry | | Severely decreased oral intake of | mucous membranes, poor skin | | water and salt | turgor, slow vein filling, flat | | | neck veins when supine, dark | | ***Increased GI output:*** | yellow urine | | vomiting, diarrhea, laxative | | | overuse, drainage from fistulas | ***If severe:*** Thirst, | | or tubes | restlessness, confusion, | | | hypotension; oliguria (urine | | ***Increased renal output:*** use | output below 30 mL/hr); cold, | | of diuretics, adrenal | clammy skin; hypovolemic shock | | insufficiency (deficit of | | | cortisol and aldosterone) | ***Laboratory findings:*** | | | Increased hematocrit; increased | | ***Loss of blood or plasma:*** | BUN above 20 mg/dL (7.1 mmol/L) | | hemorrhage, burns | (hemoconcentration); urine | | | specific gravity usually above | | Massive sweating without water | 1.030, unless renal cause | | and salt intake | | +-----------------------------------+-----------------------------------+ | **Extracellular Fluid Volume | | | Excess---Body Fluids Have | | | Increased Volume but Normal | | | Osmolality** | | +-----------------------------------+-----------------------------------+ | ***Sodium and Water Intake | ***Physical examination:*** | | Greater Than Output, Causing | Sudden weight gain (overnight), | | Isotonic Gain:*** | edema (especially in dependent | | | areas), full neck veins when | | Excessive administration of | upright or semi-upright, crackles | | Na+-containing isotonic IV fluids | in lungs | | or oral intake of salty foods and | | | water | If severe: Confusion, pulmonary | | | edema | | ***Renal retention of Na+ and | | | water:*** Heart failure, | ***Laboratory findings:*** | | cirrhosis, aldosterone or | Decreased hematocrit, decreased | | glucocorticoid excess, acute or | BUN below 10 mg/dL (3.6 mmol/L) | | chronic oliguric renal disease | (hemodilution) | +-----------------------------------+-----------------------------------+ | **Osmolality Imbalances** | | | | | | **Hypernatremia (Water Deficit; | | | Hyperosmolar Imbalance)---Body | | | Fluids Too Concentrated** | | +-----------------------------------+-----------------------------------+ | ***Loss of Relatively More Water | ***Physical examination:*** | | Than Salt:*** | Decreased level of consciousness | | | (confusion, lethargy, coma), | | Diabetes insipidus (ADH | perhaps thirst, seizures if | | deficiency) | develops rapidly or is very | | | severe | | Osmotic diuresis | | | | ***Laboratory findings:*** Serum | | Large insensible perspiration and | Na+ level above 145 mEq/L (145 | | respiratory water output without | mmol/L), serum osmolality above | | increased water intake | 295 mOsm/kg (295 mmol/kg) | | | | | ***Gain of Relatively More Salt | | | Than Water:*** | | | | | | Administration of tube feedings, | | | hypertonic parenteral fluids, or | | | salt tablets | | | | | | Lack of access to water, | | | deliberate water deprivation, | | | inability to respond to thirst | | | (e.g., immobility, aphasia) | | | | | | Dysfunction of | | | osmoreceptor-driven thirst drive | | +-----------------------------------+-----------------------------------+ | **Hyponatremia (Water Excess; | | | Water Intoxication; Hypoosmolar | | | Imbalance)---Body Fluids Too | | | Dilute** | | +-----------------------------------+-----------------------------------+ | ***Gain of Relatively More Water | ***Physical examination:*** | | Than Salt:*** | Decreased level of consciousness | | | (confusion, lethargy, coma), | | Excessive ADH (SIADH) | seizures if develops rapidly or | | | is very severe | | Psychogenic polydipsia or forced | | | excessive water intake | ***Laboratory findings:*** Serum | | | Na+ level below 136 mEq/L (136 | | Excessive IV administration of | mmol/L), serum osmolality below | | D5W | 285 mOsm/kg (285 mmol/kg) | | | | | Use of hypotonic irrigating | | | solutions | | | | | | Tap-water enemas | | | | | | ***Loss of Relatively More Salt | | | Than Water:*** | | | | | | Replacement of large body fluid | | | output (e.g., diarrhea, vomiting) | | | with water but no salt | | +-----------------------------------+-----------------------------------+ | **Combined Volume and Osmolality | | | Imbalance** | | | | | | **Clinical Dehydration (ECV | | | Deficit Plus | | | Hypernatremia)---Body Fluids Have | | | Decreased Volume and Are Too | | | Concentrated** | | +-----------------------------------+-----------------------------------+ | ***Sodium and Water Intake Less | ***Physical examination and | | Than Output, With Loss of | laboratory findings:*** | | Relatively More Water Than | Combination of those for ECV | | Salt:*** | deficit plus those for | | | hypernatremia (see previous | | All of the causes of ECV deficit | signs) | | (see previous causes) plus poor | | | or no water intake, often with | | | fever causing increased | | | insensible water output | | +-----------------------------------+-----------------------------------+ **[ABBREVIATIONS]** **ADH-**ANTIDIURETIC HORMONE **BUN-**BLOOD UREA NITROGEN **D5W-**DEXTROSE IN WATER **ECV-**EXTRACELLULAR FLUID VOLUME **GI-**GASTROINTESTINAL TRACT **IV-**INTROVENEOUS **SIADH-**SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE **[Extracellular Volume Excess-]**Occurs when there is too much isotonic fluid in the extracellular compartment (more salt than water) **[Osmolality Imbalances (HYPER or HYPOTONIC)]** **[Hypernatremia-]**Water deficit, more salt than water, water leaves the cell and then shrivels, this is also called clinical dehydration (Remember Hyper/Active) cell shrinks **[Hyponatremia-]**Water excess, more water than salt, or water intoxication, the gain of more water than salt, (Remember Hippo Large/Swollen) the cells increases in size or swells. **[Electrolyte Imbalance]** There are three processes to electrolyte imbalance: 1. Electrolyte intake and absorption 2. Electrolyte disruption 3. Electrolyte output **[Electrolytes Intake and Absorption, Intake and Output]** +-------------+-------------+-------------+-------------+-------------+ | **Intake | | | | | | and | | | | | | Important** | | | | | | | | | | | | **Electroly | | | | | | te | | | | | | Absorption | | | | | | Distributio | | | | | | n | | | | | | Output/Loss | | | | | | Functions** | | | | | +=============+=============+=============+=============+=============+ | Potassium | Fruits | Low in ECF, | Aldosterone | Maintains | | (K+) | | high in | , | resting | | | Potatoes | ICF. | black | membrane | | | | | licorice, | potential | | | Instant | Insulin, | hypomagnese | of | | | coffee | epinephrine | mia, | skeletal, | | | | , | and | smooth, and | | | Molasses | and | polyuria | cardiac | | | | alkalosis | increase | muscle, | | | Brazil nuts | shift K+ | renal | allowing | | | | into cells. | excretion; | normal | | | Absorbs | | oliguria | muscle | | | easily | Some types | decreases | function | | | | of acidosis | renal | | | | | shift K+ | excretion. | | | | | out of | | | | | | cells. | Acute or | | | | | | chronic | | | | | | diarrhea | | | | | | increases | | | | | | fecal | | | | | | excretion | | +-------------+-------------+-------------+-------------+-------------+ | Calcium | Dairy | Ca2+ is low | Thiazide | Influences | | (Ca2+) | products | in ECF, | diuretics | excitabilit | | | | mostly in | decrease | y | | | Canned fish | bones and | renal | of nerve | | | with bones | intracellul | excretion. | and muscle | | | | ar. | | cells; | | | Broccoli | | Chronic | necessary | | | | Some Ca2+ | diarrhea | for muscle | | | Oranges | in blood is | and | contraction | | | | bound and | undigested | | | | Requires | inactive; | fat | | | | vitamin D | only | increase | | | | for best | ionized | fecal | | | | absorption | Ca2+ is | excretion. | | | | | active. | | | | | Undigested | | | | | | fat | Parathyroid | | | | | prevents | hormone | | | | | absorption | shifts Ca2+ | | | | | | out of | | | | | | bone; | | | | | | calcitonin | | | | | | shifts Ca2+ | | | | | | into bone. | | | | | | | | | | | | Ca2+ | | | | | | decreases | | | | | | in blood if | | | | | | phosphate | | | | | | rises and | | | | | | vice versa. | | | +-------------+-------------+-------------+-------------+-------------+ | Magnesium | Dark green | Mg2+ is low | Rising | Influences | | (Mg2+) | leafy | in ECF, | blood | function of | | | vegetables | mostly in | ethanol | neuromuscul | | | | bones and | increases | ar | | | Whole | intracellul | renal | junctions; | | | grains | ar. | excretion; | is a | | | | | oliguria | cofactor | | | Mg2+-contai | Some Mg2+ | decreases | for | | | ning | in blood is | renal | numerous | | | laxatives | bound and | excretion. | enzymes | | | and | inactive; | | | | | antacids | only free | Chronic | | | | | Mg2+ is | diarrhea | | | | Undigested | active. | and | | | | fat | | undigested | | | | prevents | | fat | | | | absorption | | increase | | | | | | fecal | | | | | | excretion. | | +-------------+-------------+-------------+-------------+-------------+ | Phosphate | Milk | Phosphate | Oliguria | Necessary | | | | is low in | and | for | | | Processed | ECF; it is | elevated | production | | | foods | higher in | fibroblast | of ATP, the | | | | ICF and in | growth | energy | | | Aluminum | bones. | factor 23 | source for | | | antacids | | (FGF-23) | cellular | | | prevent | Insulin and | decrease | metabolism | | | absorption | epinephrine | renal | | | | | shift | excretion. | | | | | phosphate | | | | | | into cells. | | | | | | | | | | | | Decreases | | | | | | in blood if | | | | | | calcium | | | | | | rises and | | | | | | vice versa. | | | +-------------+-------------+-------------+-------------+-------------+ **[Factors Affecting Electrolyte Imbalance]** - Diarrhea - Endocrine Disorders - Medications **NOTE:** If electrolyte **intake** is **greater** than **output** or a shift of electrolytes from cells or bone into the ECF it will cause **plasma electrolyte excess**. **NOTE:** If electrolyte **intake** is **less** than **output** or shift from ECF into cells and bones it will cause a **blood plasma deficit**. +-----------------------------------+-----------------------------------+ | **[ELECTROLYTE | | | IMBALANCES]** | | | | | | **Imbalance and Related Causes | | | Signs and Symptoms** | | +===================================+===================================+ | **Hypokalemia**---**Low Serum | | | Potassium (K+) Concentration** | | +-----------------------------------+-----------------------------------+ | ***Decreased K+ Intake:*** | ***Physical examination:*** | | Excessive use of K+-free IV | Bilateral muscle weakness that | | solutions | begins in quadriceps and may | | | ascend to respiratory muscles, | | ***Shift of K+ Into Cells:*** | abdominal distention, decreased | | Alkalosis; treatment of diabetic | bowel sounds, constipation, | | ketoacidosis with insulin | dysrhythmias | | | | | ***Increased K+ Output:*** Acute | ***Laboratory findings:*** Serum | | or chronic diarrhea; vomiting; | K+ level below 3.5 mEq/L (3.5 | | other GI losses (e.g., | mmol/L) | | nasogastric or fistula drainage); | | | use of potassium-wasting | ***ECG abnormalities:*** U waves; | | diuretics; aldosterone excess; | flattened or inverted T waves; ST | | polyuria; glucocorticoid therapy | segment depression | +-----------------------------------+-----------------------------------+ | **Hyperkalemia**---**High Serum | | | Potassium (K+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Increased K+ Intake:** | **Physical examination:** | | Iatrogenic administration of | Bilateral muscle weakness in | | large amounts of IV K+; rapid | quadriceps, transient abdominal | | infusion of stored blood; excess | cramps, diarrhea, dysrhythmias, | | ingestion of K+ salt substitutes | cardiac arrest if severe | | | | | **Shift of K+ out of Cells:** | Laboratory findings: Serum K+ | | Massive cellular damage (e.g., | level above 5 mEq/L (5 mmol/L) | | crushing trauma, cytotoxic | | | chemotherapy); insufficient | **ECG abnormalities:** Peaked T | | insulin (e.g., diabetic | waves; widened QRS complex; PR | | ketoacidosis); some types of | prolongation; terminal sine-wave | | acidosis | pattern | | | | | **Decreased K+ Output:** Acute or | | | chronic oliguria (e.g., severe | | | ECV deficit, end-stage renal | | | disease); use of | | | potassium-sparing diuretics; | | | adrenal insufficiency (deficit of | | | cortisol and aldosterone) | | +-----------------------------------+-----------------------------------+ | **Hypocalcemia**---**Low Serum | | | Calcium (Ca2+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Decreased Ca2+ Intake and | **Physical examination:** | | Absorption:** Calcium-deficient | Numbness and tingling of fingers, | | diet; vitamin D deficiency | toes, and circumoral (around | | (includes end-stage renal | mouth) region, positive Chvostek | | disease); chronic diarrhea; | sign (contraction of facial | | laxative misuse; steatorrhea | muscles when facial nerve is | | | tapped), hyperactive reflexes, | | Shift of Ca2+ Into Bone or | muscle twitching and cramping; | | **Inactive Form:** | carpal and pedal spasms, | | Hypoparathyroidism; rapid | Trousseau\'s sign is a medical | | administration of citrated blood; | sign that indicates low calcium | | hypoalbuminemia; alkalosis; | levels in the blood, or | | pancreatitis; hyperphosphatemia | hypocalcemia. It\'s characterized | | (includes end-stage renal | by involuntary hand and wrist | | disease) | muscle contractions, or | | | carpopedal spasms, that occur | | **Increased Ca2+ Output:** | after inflating a blood pressure | | Chronic diarrhea; steatorrhea | cuff on the upper arm, tetany, | | | seizures, laryngospasm, | | | | | | dysrhythmias | | | | | | **Laboratory findings:** Total | | | serum Ca2+ level below 9.0 mg/dL | | | (2.25 mmol/L) or serum ionized | | | Ca2+ level below 4.5 mg/dL (1.05 | | | mmol/L) | | | | | | **ECG abnormalities:** Prolonged | | | ST segments | +-----------------------------------+-----------------------------------+ | **Hypercalcemia**---**High Serum | | | Calcium (Ca2+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Increased Ca2+ Intake and | **Physical examination**: | | Absorption:** Milk-alkali | Anorexia, nausea and vomiting, | | syndrome | constipation, fatigue, diminished | | | reflexes, lethargy, decreased | | Shift of Ca2+ out of Bone: | level of consciousness, | | Prolonged immobilization; | confusion, personality change, | | hyperparathyroidism; bone tumors; | cardiac arrest if severe | | nonosseous cancers that secrete | | | bone-resorbing factors | **Laboratory findings:** Total | | | serum Ca2+ level above 10.5 mg/dL | | **Decreased Ca2+ Output**: Use of | (2.62 mmol/L) or serum ionized | | thiazide diuretics | Ca2+ level above 5.6 mg/dL (1.3 | | | mmol/L) | | | | | | **ECG abnormalities:** Heart | | | block, shortened ST segments | +-----------------------------------+-----------------------------------+ | **Hypomagnesemia**---**Low Serum | | | Magnesium (Mg2+) Concentration** | | +-----------------------------------+-----------------------------------+ | **Decreased Mg2+ Intake and | **Physical examination:** | | Absorption:** Malnutrition; | Positive Chvostek sign, | | chronic alcoholism; chronic | hyperactive deep tendon reflexes, | | diarrhea; laxative misuse; | muscle cramps and twitching, | | steatorrhea | grimacing, dysphagia, tetany, | | | seizures, insomnia, tachycardia, | | **Shift of Mg2+ Into Inactive | hypertension, dysrhythmias | | Form:** Rapid administration of | | | citrated blood | **Laboratory findings:** Serum | | | Mg2+ level below 1.3 mEq/L (0.65 | | **Increased Mg2+ Output:** | mmol/L) | | Chronic diarrhea; steatorrhea; | | | other GI losses (e.g., vomiting, | ECG abnormalities: Prolonged QT | | nasogastric or fistula drainage); | interval | | use of thiazide or loop | | | diuretics; aldosterone excess | | +-----------------------------------+-----------------------------------+ | **Hypermagnesemia**---**High | | | Serum Magnesium (Mg2+) | | | Concentration** | | +-----------------------------------+-----------------------------------+ | **Increased Mg2+ Intake and | **Physical examination:** | | Absorption:** Excessive use of | Lethargy, hypoactive deep tendon | | Mg2+-containing laxatives and | reflexes, bradycardia, | | antacids; parenteral overload of | hypotension | | mag nesium | | | | **Acute elevation in Mg2+ | | **Decreased Mg2+ Output:** | levels:** Flushing, sensation of | | Oliguric end-stage renal disease; | warmth | | adrenal insufficiency | | | | **Severe acute hypermagnesemia:** | | | Decreased rate and depth of | | | respirations, dysrhythmias, | | | cardiac arrest | | | | | | **Laboratory findings:** Serum | | | Mg2+ level above 2.1 mEq/L (1.05 | | | mmol/L) | | | | | | ECG abnormalities: Prolonged PR | | | interval | +-----------------------------------+-----------------------------------+ **[NORMAL VALUES]** \(P) *Stands for* pH A\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--B *Primary* 7.35 7.45 Source *The 2* PaCO2 A\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--B *Reminds* (**LUNGS)** 35 RESPIRATORY 45 *You this* *Is Second* *(Drop the Sevens* *They go to Heaven)* *The 3* HCO3 A\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--B *Reminds* **(KIDNEYS)** 35 METABOLIC 45 *You this is the* *Third value* **[ACID PRODUCTION]** TWO TYPES - Carbonic- Lungs-(CO2+H2O)= H2CO3 - Metabolic-Kidneys (any acids that are not carbonic **[ACID BUFFERING]** Pairs of chemicals that work together to maintain normal pH. All body fluids contains, one major buffer in ECF is Bicarbonate (HCO3)-buffers metabolic acid. **[ACID EXCRETION]** 2 Acid excretion systems - Lungs-Respiratory/carbonic - Kidneys-Metabolic/anything but carbonic **[Excretion of carbonic acid-]**when we exhale, we blow off carbon dioxide (CO2) and water. \* If PaCO2 decreases-chemoreceptors trigger slower/ shallower respirations, so that more CO2 produced remains in the blood. \*If PaCO2 increases chemoreceptors are triggered and cause faster/deeper respirations. People with respiratory disease may not be able to blow off CO2- so their blood becomes acidic. If lungs cannot correct the issue then the kidneys will begin compensating and excrete metabolic acid. **[Excretion of Metabolic Acid-]** Kidneys excrete all acids except carbonic acid. \*Phosphate buffers in the renal tubular fluid keep the urine from becoming too acidic. If there are too many H+ ions in the urine, then renal tubular cells excrete ammonia. This process enables metabolic acid excretion through the urine. People who have oliguric kidney disease cannot excrete metabolic acid the acids accumulate in the blood triggering the lungs to increase respiratory rate and depth to cause compensator excretion of carbonic acid. **[Acid Base Imbalance]** Acidosis- increased pH Alkalosis-increased base (bicarbonate) **2 types of acidosis** - Respiratory-Lungs - Metabolic-Kidneys - Respiratory-Lungs - Metabolic-Kidneys **NOTE:** Both lungs and kidneys have a compensatory system that engages when one or the other cannot self-correct the imbalances. **[Acid base imbalances]** +-----------------------------------+-----------------------------------+ | Imbalance and Related Causes | | | Signs and Symptoms | | +===================================+===================================+ | **Respiratory | | | Acidosis**---Excessive Carbonic | | | Acid Caused by Alveolar | | | Hypoventilation | | +-----------------------------------+-----------------------------------+ | **Impaired Gas Exchange:** | **Physical examination:** | | | Headache, light-headedness, | | Type B COPD (chronic bronchitis) | decreased level of consciousness | | or end-stage type A COPD | (confusion, lethargy, coma), | | (emphysema) | dysrhythmias | | | | | Bacterial pneumonia | **Laboratory findings:** Arterial | | | blood gas alterations: pH below | | Airway obstruction | 7.35, PaCO2 above 45 mm Hg (6 | | | kPa), HCO3− level normal if | | Extensive atelectasis (collapsed | uncompensated or above 28 mEq/L | | alveoli) | (28 mmol/L) if compensated | | | | | Severe acute asthma episode | | | | | | **Impaired Neuromuscular | | | Function:** | | | | | | Respiratory muscle weakness or | | | paralysis from hypokalemia or | | | neurological dysfunction | | | | | | Respiratory muscle fatigue, | | | respiratory failure | | | | | | Chest wall injury or surgery | | | causing pain with respiration | | | | | | **Dysfunction of Brainstem | | | Respiratory Control:** | | | | | | Drug overdose with a respiratory | | | depressant | | | | | | Some types of head injury | | +-----------------------------------+-----------------------------------+ | **Respiratory | | | Alkalosis**---Deficient Carbonic | | | Acid Caused by Alveolar | | | Hyperventilation | | +-----------------------------------+-----------------------------------+ | Hypoxemia from any cause (e.g., | **Physical examination:** | | initial part of asthma episode, | Light-headedness, numbness and | | pneumonia) | tingling of fingers, toes, and | | | circumoral region, increased rate | | Acute pain | and depth of respirations, | | | excitement and confusion possibly | | Anxiety, psychological distress, | followed by decreased level of | | sobbing | consciousness, dysrhythmias | | | | | Inappropriate mechanical | **Laboratory findings:** Arterial | | ventilator settings | blood gas alterations: pH above | | | 7.45, PaCO2 below 35 mm Hg (4.7 | | Stimulation of brainstem | kPa), HCO3− level normal if short | | respiratory control (e.g., | lived or uncompensated or below | | meningitis, gram-negative sepsis, | 21 mEq/L (21 mmol/L) if | | head injury, aspirin overdose) | compensated | +-----------------------------------+-----------------------------------+ | **Metabolic | | | Acidosis**---Excessive Metabolic | | | Acids | | +-----------------------------------+-----------------------------------+ | **Increase of Metabolic Acids | **Physical examination:** | | (High Anion Gap):** | Light-headedness, numbness and | | | tingling of fingers, toes, and | | Ketoacidosis (diabetes, | circumoral region; muscle cramps; | | starvation, alcoholism) | possible excitement and confusion | | | followed by decreased level of | | Hypermetabolic state (severe | consciousness, dysrhythmias (may | | hyperthyroidism, burns, severe | be caused by concurrent | | infection) | hypokalemia) | | | | | Oliguric renal disease (acute | **Laboratory findings:** Arterial | | kidney injury, end-stage renal | blood gas alterations: pH above | | disease) | 7.45, PaCO2 normal if | | | uncompensated or above 45 mm Hg | | Circulatory shock (lactic | (6.0 kPa) if compensated, HCO3− | | acidosis) | above 28 mEq/L (28 mmol/L) | | | | | Ingestion of acid or acid | | | precursors (e.g., methanol, | | | ethylene glycol, boric acid) | | | | | | **Loss of Bicarbonate (Normal | | | Anion Gap):** | | | | | | Diarrhea | | | | | | Pancreatic fistula or intestinal | | | decompression | | | | | | Renal tubular acidosis | | +-----------------------------------+-----------------------------------+ | **Metabolic | | | Alkalosis**---Deficient Metabolic | | | Acids | | +-----------------------------------+-----------------------------------+ | **Increase of Bicarbonate:** | **Physical examination:** | | | Light-headedness, numbness and | | Excessive administration of | tingling of fingers, toes, and | | sodium bicarbonate | circumoral region; muscle cramps; | | | possible excitement and confusion | | Massive blood transfusion (liver | followed by decreased level of | | converts citrate to HCO3−) | consciousness, dysrhythmias (may | | | be caused by concurrent | | Mild or moderate ECV deficit | hypokalemia) | | (contraction alkalosis) | | | | **Laboratory findings:** Arterial | | **Loss of Metabolic Acid:** | blood gas alterations: pH above | | | 7.45, PaCO2 normal if | | Excessive vomiting or gastric | uncompensated or above 45 mm Hg | | suctioning | (6.0 kPa) if compensated, HCO3− | | | above 28 mEq/L (28 mmol/L) | | Hypokalemia | | | | | | Excess aldosterone | | +-----------------------------------+-----------------------------------+ **[Respiratory Acidosis (HYPOVENTALATION)]** - **Causes** - Excessive carbonic acid by alveolar (***hypoventilation)*** - Caused by impaired gas exchange - Type B COPD - End stage type A COPD - Bacterial Pneumonia - Airway Obstruction - Extensive Atelectasis (Collapsed Alveoli) - Severe acute asthma - **Neuromuscular Causes** - Respiratory muscle weakness from paralysis from hypokalemia or neurological dysfunction - Respiratory muscle fatigue, respiratory failure - Chest wall injury or surgery causing pain with respiration - **Other Causes** - Dysfunction of the brainstem respiratory control - - Drug overdose with respiratory depressant - Some types of head injuries **[Signs and Symptoms]** - Headache - Light headed - Decreased level of consciousness - Confusion - Lethargy - Coma - Dysrhythmias **[Lab Findings]** - pH-decreased - PaCO2-increased - HCO3-if normal (uncompensated) if increased (partial compensation) **[Respiratory Alkalosis HYPERVENTALATION]** - **Causes** - Hypoxemia - Acute Pain - Anxiety - Psychological Distress - Sobbing - Inappropriate Mechanical Ventilator Setting - Stimulation of the brainstem respiratory control (i.e. meningitis, gram negative sepsis, head injury, aspirin overdose) - **Signs and Symptoms** - Light headedness - Numbness - Tingling of fingers, toes and circumoral region - Increased rate and depth of respirations - Excitement - Confusion, followed by decreased levels of consciousness - Dysrhythmias - **Lab Values** - pH Increased above 7.45 - PaCO2 decreased below 35 - HCO3 Normal (Uncompensated) below 21 (partially compensated) **[Metabolic Acidosis---Excessive metabolic acids]** - **Causes:** - Increase of metabolic acids (high anion gap) - Ketoacidosis - Hypermetabolic State (severe hypothyroidism, burns, severe infection) - Oliguric renal disease (acute kidney injury, end stage renal disease) - Circulating shock (lactic acidosis) - Ingestion of acid or acid precursors (i.e. methanol, ethylene, glycol, boric acid) - Loss of Bicarbonate (Normal anion gap) - Diarrhea - Pancreatic Fistula or intestinal decompression - Renal tubular acidosis - **Signs and Symptoms:** - Decreased level of consciousness - Lethargy, confusion, coma - Abdominal pain - Dysrhythmias - Increased rate and depth of respirations (compensatory hyperventilation) - **Lab Findings** - pH decreased below 7.35 - PaCO2 normal (uncompensated) below 35 (partially compensated) - HCO3 below 21 **[Metabolic Alkalosis deficit in metabolic acids]** - **Causes:** - Increase Bicarbonate - Excessive administration of sodium bicarbonate - Massive blood transfusion (liver converts citrates to HCO3) - Mild or moderate ECV deficit (contraction alkalosis) - Loss of metabolic acid - Excessive vomiting or gastric suctioning - Hypokalemia - Excessive aldosterone - **Signs and Symptoms:** - Light headedness - Numbness and tingling fingers, toes and circumoral region - Muscle cramps - Possible excitement and confusion followed by decreased levels of consciousness - Dysrhythmias - Concurrent hypokalemia - **Lab Findings** - pH increased above 7.45 - PaCO2 normal (uncompensated) above 45 (partially compensated) - HCO3 increased above 28 **[Respiratory Alkalosis-]**(Hyperventilation) lungs excrete, too much CO2 and water, **short lived,** therefore kidneys do not have enough to compensate. If pH rises high enough CNS depression can occur. **[Metabolic Acidosis-]**Increased metabolic or decreased base bicarbonate, kidneys are unable to excrete metabolic acids they then accumulate in the blood (or) bicarb is removed directly from the body (diarrhea) (anion gap) decreased pH stimulates chemoreceptors, lungs compensate by hyperventilation. **[Respiratory Acidosis-]**Increased CO2, Increased PaCO2, causes hypoventilation the kidneys compensate by excretion of metabolic acids in the urine. **[Risk Factors of Imbalances]** - **Age** - Young (ECV deficit) (Osmolality imbalances) (Clinical dehydration) - Old (ECV excess or deficit) (osmolality imbalance) - **Environmental** - Sodium rich diet (ECV excess) - Electrolyte poor diet (electrolyte deficits) - Hot weather (clinical dehydration) - **Gastrointestinal Output** - Diarrhea - Drainage - Vomiting - **Chronic Disease** - Cancer - COPD - Cirrhosis - HF - Oliguric renal disease - **Trauma** - Burns - Crash Injuries - Head Injuries - Hemorrhage - **Therapies** - Diuretics - IV Therapy - PN **[Different types of RN Diagnosis for Fluid, Electrolyte or Acid Alteration]** Fluid Imbalance Dehydration Acid Base Imbalance Lack of knowledge of fluid regimen **NOTE:** In acute care fluid, electrolyte and acid base imbalances are very common **[Enteral Fluid Replacement]** (By Mouth) Remember ice chips are ½ of a volume measurement i.e. give a pt 240 mL of ice chips the actual intake volume is 120 mL - **[Contraindications for enteral fluid replacement]** - Mechanical Obstruction of GI tract - Severe Nausea - Increased risk of aspiration - Impaired swallowing **[Parenteral Fluid Replacement]** (IV) - **[Types of Fluid Replacement]** - PN (Parenteral Nutrition) - Electrolyte therapy - Blood - Blood Components **[Types of IV Solutions]** - D5W-Dextrose 5% in water - D10W-Dextrose 10% in water **Saline Chloride (NaCl) in water solution** - 0.225% NaCl (1/4 Normal Saline) - 0.45% NaCl (1/2 Normal Saline) - 0.9% NaCl (normal saline) - 3-5% NaCl (hypertonic saline) **Dextrose in Saline Solution** - Dextrose 5% in 0.45% NaCl (1/2 normal saline) - Dextrose 5% in 0.9% NaCl (D5NS) **Multiple Electrolyte Solutions** - Lactated Ringers (LR) - Dextrose 5% (LR, D5LR) **[Chapter 45 Nutrition]** Albumin Anorexia Nervosa Basal Metabolic Rate (BMR) Body Mass Index (BMI) Bulimia Nervosa Carbohydrates Catabolism Chyne Daily Values Dietary Reference Dietary Reference Intakes (DRI's) Dispensable Amino Acids Dysphagia Enteral Nutrition (EN) Fat Soluble Vitamins Fiber Food Security Hypervitaminosis Ideal Body Weight (IBW) Indispensable amino acids Insulin Intravenous Ketones Kilocalories Lipids Macrominerals Malabsorption Malnutrition Medical Nutrition Therapy (MNT) Metabolism Minerals Nitrogen Balance Parenteral Nutrition (PN) Peristalsis Resting Energy Expenditure (REE) Simple Carbohydrates Trace Elements Triglycerides Vitamins Water Soluble Vitamins Villi **[Biochemical Units of Nutrition]** The body requires fuel to provide energy for cellular metabolism and repair, organ function, growth and body movement. **[Factors affecting Energy Requirements]** - Age - Body mass - Gender - Fever - Starvation - Menstruation - Illness - Injury - Infection - Activity - Level of thyroid function **[Factors affecting Metabolism]** - Illness - Pregnancy - Lactation - Activity level **[Proteins:]** provide a source of energy equal to 4Kcal/g; they are essential for the growth, maintenance, and repair of body tissue. Collagen, hormones, enzymes, immune cells, (DNA), (RNA) are all made of protein. **[Factors of Protein]** The following important factors of the functioning human body require protein - Blood Clotting - Fluid Regulation - Acid-Base Balance **[Water:]** is critical because all cell function depends on a fluid environment. Water makes up to 60-70% of total body weight. People who are lean have a greater percentage of water because muscle contains more water than any other tissue *except* blood. **[Fluid Release]** - Respiration - Sweating - Urine - Stools - Fever - Vomiting - Trauma (blood loss) - Clinical Dehydration - Medications **[Digestion of Food:]** is the mechanical breakdown that results from chewing, churning, and mixing with fluid and chemical reactions in which food is reduced to its simplest form. A diagram of the internal organs of a person Description automatically generated **[Enzymes:]** are protein-like substances that act as a catalyst to speed up chemical reactions. They are an essential part of the chemistry of digestion. **[Factors that affect Nutrition]** - Environmental-this is beyond the control of the patient and contributes to obesity. 68.7 % of Americans are overweight or obese. Overweight Measurement: BMI 25 to 29 Obese Measurement: BMI of 30 or greater Cost of healthy food is increasing unable to afford, and there are fewer safe places to walk and play. - Age-Older adults 65 and up have a decreased need for energy because their metabolic rate slows with age. However, vitamin and mineral requirements remain unchanged. - Age related changes - Decreased appetite - Decreased taste cells - Decreased income - Increase cost of medication/ making it difficult to balance between medication and food and other monthly bills - Decreased health - No desire to eat - Lack of transportation - Specific Diet affects nutrition **[Vegetarian Diet]**-is the consumption of predominantly plant foods **[Physical Signs and Symptoms of Altered Nutrition]** **[Body Area Indicators of Malnutrition]** General appearance Easily fatigued, no energy, falls asleep easily; looks tired, apathetic, cachectic ------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------- Weight Overweight, obese, or underweight (special concern for underweight); unplanned weight loss over period of time Posture Poor posture, sagging shoulders, sunken chest, humped back Muscles Flaccid, weak, poor tone, tender; "wasted" appearance; impaired mobility Mental status Inattentive, irritable, confused Neurological function Burning and tingling of hands and feet (paresthesia), loss of position and vibratory sense, decrease or loss of ankle and knee reflexes Gastrointestinal function Anorexia, indigestion, constipation or diarrhea, symptoms of malabsorption, liver or spleen enlargement, abdominal distention Cardiovascular function Tachycardia, abnormal rhythm, elevated blood pressure Hair Stringy, dull, brittle, dry, thin and sparse, depigmented Skin (general) Rough, dry, scaly, pale, pigmented, irritated, bruises, petechiae Face and neck Swollen, skin dark over cheeks and under eyes Lips Dry, scaly, swollen; redness and swelling at the corners of the mouth (cheilosis); angular lesions at corners of mouth, fissures, or scars (stomatitis) Mouth, oral mucous membranes Swollen, deep red oral mucous membranes; oral lesions Gums Spongy, bleed easily, inflamed, receding Tongue Swelling, scarlet and raw, magenta color, beefy (glossitis) Teeth Missing teeth, broken teeth Eyes Eye membranes pale (pale conjunctivae), redness of membrane (conjunctival injection), dryness or infection Nails Spoon-shaped (koilonychia), brittle, ridged Legs and feet Edema, tender calf, tingling, weakness, lesions Skeleton Bowlegs, knock-knees, chest deformity at diaphragm, beaded ribs, prominent scapulas **[Anthropometry-]**A systemic method of measuring the size and makeup of the body. **[Weight-]**Measure the patient's weight at the same time of day every day, same scale, and with comparable clothing. If patient has lost or gained 3 or more pounds in a 24 hour period use critical thinking to assess fluid retention, or dehydration, these will cause fluid shifts. **[BMI-]**To calculate Body Mass Index convert the patient's weight, from pounds to kg then divide the patients height in meters squared by the patients kg. (i.e. 180 lbs / 2.2 /5.6 or 1.67 m 2 = 29.34. This patient is overweight and on the cusp of being obese. **[Laboratory and Biochemical Tests:]** Are used to diagnose malnutrition, fluid balance, liver function, kidney function and the presence of disease. **[Dysphagia- (Difficult Swallowing) Causes]** **Myogenic** - Myasthenia gravis - Aging - Muscular dystrophy - Polymyositis **Neurogenic** - Stroke - Cerebral palsy - Guillain- Barre Syndrome - Multiple Sclerosis - Amyotrophic Lateral Sclerosis - Diabetic Neuropathy - Parkinson's Disease **Obstructive** - Benign peptic stricture - Lower esophageal ring - Candidiasis - Head and neck cancer - Inflammatory masses - Trauma/ surgical restriction **Other** - Gastrointestinal or esophageal resection - Rheumatological disorders - Connective tissue disorders - Vagotomy **NOTE:** **Be aware of warning signs for dysphagia. They include cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger of swallow, and inability to speak consistently are other signs of dysphagia. Patients with dysphagia often do not show overt signs such as coughing when food enters the airway.** **[Silent aspiration-]**is aspiration that occurs in patients with neurological problems that leads to decreased sensation. **NOTE:** Patients who are in (ACUTE CARE) NIP and receive only standard IV fluids for more than 5-7 days are at high nutritional risk. **[Diet Progression & Therapeutic Diets]** **[Clear Liquid-]**Consists of broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, fruit ices and popsicles **[Full Liquid-]**Same as clear, adding smooth textured dairy products. Strained or blended cream soups, custards, refined or cooked cereals, vegetable juice, pureed vegetables, all fruit juices, sherberts, puddings, and frozen yogurt. **[Dysphagia Stages-]**Thickened liquids and purees. Same as above added scrambled eggs, pureed meats, vegetables, fruits and mash potatoes and gravy. **[Mechanical Soft-]**Same as above but added creamed soups, ground or finely diced meats, flacked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, bananas, soups, peanut butter, eggs (not fried) **[Soft Low Residue-]**Easily digested foods, pasta, casseroles, moist tender meats, cooked fruits and vegetables, deserts, cakes, and cookies without nuts or coconut. **[High Fiber-]**Uncooked fruits and steamed vegetables, bran, oatmeal, and dried fruit **[Low Sodium-]**no added salts **[Diabetic-]**Focuses on total energy, nutrient and food distribution; balanced intake of carbohydrates, fats, and proteins. Varied caloric recommendations to accommodate patients metabolic demands. **[Gluten Free-]**No wheat, oats, rye, barley, and their derivatives **[Regular Diet-]**No restrictions **[Promoting Diet or Food Intake]** - Environment free of odors - Providing oral hygiene - Maintaining patient comfort - Offer smaller meals more frequently **[Four Levels of Diet for Dysphasia]** - Dysphagia puree - Dysphagia Mechanically Altered - Dysphagia Advanced - Regular **[Enteral Nutrition-]**Provides nutrients to the GI tract, by way of NG tube, or surgical feeding tube. **[Indications for EN]** - Cancer - Head/Neck Upper GI - Critical Illness or Trauma - Brain Neoplasm - Cerebrovascular Accident - Dementia - Myopathy - Enterocutaneous Fistula - Inflammatory bowel disease - Mild pancreatitis - Respiratory Failure with prolonged intubation - Anorexia Nervosa - Difficulty Chewing or Swallowing - Severe Depression **[Parenteral Nutrition-]** Specialized nutrition support through intravenous route. **[Indications of PN]** **Nonfunctioning GI Tract** - Massive small bowel resection - GI surgery - GI Bleed - Paralytic ileus - Intestinal Obstruction - Trauma to abdomen, head, neck - Sever Malabsorption - Intolerance to enteral feeding - Chemotherapy, radiation, bone marrow transplants **NOTE:** Complications of PN can be tension pneumo thorax from the tube insertion getting into the plural space of the lung, monitor patient for this complication up to 24 hours after insertion. **NOTE:** Once the patient reaches 1/3 to ½ of daily Kcal intake per day, they can be moved from PN/EN feeding. **[Impaired or Low Nutritional Intake]** **Assessment Activities Assessment Findings** +-----------------------------------+-----------------------------------+ | Changes in weight | 72-year-old woman | | | | | | 24-lb (10.8-kg) weight loss | | | | | | Weight is 20% below her ideal | | | body weight | +===================================+===================================+ | Body mass index (BMI) | BMI = 17 | +-----------------------------------+-----------------------------------+ | 24-hour food and fluid history | Does not eat breakfast | | | | | | Frequently skips dinner | | | | | | Eats sandwich in afternoon | | | | | | Caloric intake is less than daily | | | requirement | | | | | | Fluid intake is juice and coffee | +-----------------------------------+-----------------------------------+ | Physical assessment | Poor muscle tone | | | | | | Fatigue | | | | | | Hair loss | | | | | | Dry, scaly skin | | | | | | Pale conjunctiva and mucous | | | membranes | +-----------------------------------+-----------------------------------+ | Medication history | Takes antidepressant for | | | depression | +-----------------------------------+-----------------------------------+ | Social | Husband died 9 months ago | | | | | | Has quit attending monthly | | | quilting club | | | | | | Started counseling 3 months ago | +-----------------------------------+-----------------------------------+ **[Medical Nutrition Therapy-]**Is the use of specific nutritional therapies used to treat an illness, injury or condition. **[Gastrointestinal Diseases]** - Helicobacter Pylori-Peptic Ulcers - Inflammatory Bowel Disease - Idiopathic Ulcerative Colitis - Celiac Disease - Diverticulitis **[Safety Guidelines For NG Placement]** 1. All candidates for NG or nasointestinal tube placement require an assessment of their coagulation status. Anticoagulation and bleeding disorders pose a risk for epistaxis during nasal tube placement. 2. Nasal tubes are associated with sinusitis, otitis, vocal cord paralysis, and medical device--related pressure injuries (MDRPIs) to the nose. 3. Use ENFit connectors for all enteral nutrition sets, syringes, and feeding tubes to prevent instillation of feeding into a different device (e.g., IV or drainage tube). Verify connector with each administration of tube feeding (TFC, 2014). 4. Use aseptic technique when preparing and delivering enteral feedings. Check agency policy for wearing gloves when handling feedings (Harding et al., 2020). 5. Label enteral equipment with patient name and room number; formula name, rate, and date and time of initiation; and nurse initials (Ukleja et al., 2018). 6. Practice "right patient, right formula, right tube, right ENFit adapter" by matching formula and rate to feeding order and verifying that the enteral tubing set connects formula to a feeding tube (Harding et al., 2020). 7. Position the patient upright or elevate the head of the bed a minimum of 30 (preferably 45) degrees unless medically contraindicated for patients receiving enteral feedings (Ukleja et al., 2018; ASPEN 2021). 8. Trace all lines and tubing back to the patient to ensure only enteral-to-enteral connections (Ukleja et al., 2018). 9. Do not add food coloring or dye to EN because the use of dye has been linked to hypotension, metabolic acidosis, and death (Harding et al., 2020). 10. Refer to manufacturer guidelines to determine hang time for enteral feedings. Maximum hang time for formula is 8 hours in an open system and 24 to 48 hours in a closed, ready-to-hang system (if it remains closed). There is increased risk of bacterial growth in feedings that exceed the recommended hang time. 11. Follow standard ANTT® practices when manipulating parts of the IV infusion for PN. 12. Always use the appropriate type of infusion pump for continuous enteral feedings and PN. 13. Be alert for signs of aspiration during oral feedings as well as when EN is administered. 14. Clean and disinfect a point-of-care (POC) blood glucose testing meter after each patient use. **[Aspiration Precautions]** The skill of following aspiration precautions while feeding a patient can be delegated to assistive personnel (AP). However, the nurse is responsible for the ongoing assessment of a patient's risk for aspiration and determination of positioning and any special feeding techniques. The nurse directs the AP to: Position patient upright (45--90 degrees preferred) or according to medical restrictions during and after feeding. Use aspiration precautions while feeding patients who need help and explain feeding techniques that are successful for specific patients. Immediately report any onset of coughing, gagging, or a wet voice or pocketing of food to the nurse. STEPS RATIONALE/ ASSESSMENT 1\. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. **Rationale:** *Ensures correct patient.* 2\. Review patient's medical history, nutritional risks, and results of nutritional screening in medical record. Assess for presence of conditions that cause dysphagia **Rationale:** *Reveals patient risk patterns for altered nutrition and dysphagia. Weight provides baseline for determining change in nutritional status.* 3\. Assess patient's current medications for use of sedatives, hypnotics, or other agents that may impair cough or swallowing reflex and for any medications that dry oral secretions **Rationale:** *Medication side effects may increase risk of developing dysphagia.* 4\. Perform hand hygiene. Assess patient for signs and symptoms of dysphagia. Use a screening tool if agency recommended. Refer to SLP or RD if findings are positive for dysphagia. **Rationale:** *Patient symptoms aid in determining whether further swallow evaluation is needed and approach to feeding.* 5\. Assess patient's or family caregiver's health literacy. **Rationale:** *Ensures patient has the capacity to obtain, communicate, process, and understand basic health information* 6\. Assess patient's mental status: alertness, orientation, and ability to follow simple commands (e.g., open your mouth; stick out your tongue). **Rationale:** *Disorientation and inability to follow commands present higher risk for dysphagia. Patients with progressive dementia develop dysphagia.* 7\. Apply gloves. Assess patient's oral cavity, level of dental hygiene, missing teeth, or poorly fitting dentures. Remove and dispose of gloves. **Rationale:** *Poorly fitting dentures and absence of teeth can cause chewing and swallowing difficulties, increasing aspiration risk. Poor oral hygiene and periodontal disease can result in growth of bacteria in oropharynx, which if aspirated can lead to pneumonia. Findings indicate level of oral hygiene needed and diet selection needed.* 8\. Option: Apply pulse oximeter to obtain baseline assessment of oxygen saturation. Keep oximeter in place. A decline in SpO2 ≥2% has been regarded as a possible marker of aspiration. Perform hand hygiene. **Rationale:** *Despite its clinical use, research findings question whether oximetry can reliably detect aspiration. Monitoring of SpO2 during feeding may detect developing problem.* 9\. Prepare to observe patient during mealtime for signs of dysphagia. Observe patient attempt to feed self; note type of food consistencies and liquids able to swallow. Note during and at end of meal if patient tires. **Rationale:** *Detects abnormal eating patterns such as frequent clearing of throat or prolonged eating time. Chewing and sitting up for feeding bring on onset of fatigue. Provides data for future planning of meal assistance.* 10\. Indicate in patient's health record that dysphagia/aspiration risk is present. Option: Some agencies use different-colored meal trays to signify patients at risk for aspiration. **Rationale:** *Identifying patients with dysphagia reduces risk that they will receive improperly prepared oral nutrition without supervision.* 11\. Assess patient's or family caregiver's knowledge of and experience with dysphagia risk, diet options, and aspiration precautions. **Rationale:** *Reveals need for patient instruction and/or support.* 12\. Assess patient's goals or preferences for how you should provide assistance with eating. Ask for patient or family caregiver's commitment to plan. **Rationale:** *Matching your approach with patient outcomes will likely improve patient's participation. Initial commitment from a learner is critical. The learner processes information just collected from the assessment and articulates own plan.* **PLANNING** 4. Provide patient 30-minute rest time before meals. **Rationale:** *Some practitioners recommend rest time before meals. Muscle weakness and fatigue may increase risk of aspiration.* 5. Explain to patient why you are observing him or her while eating. Discuss signs and symptoms of aspiration. Teach patient how to perform aspiration precautions as appropriate. **Rationale:** *Reduces anxiety and promotes cooperation.* Signs or symptoms associated with aspiration indicate need for further swallowing evaluation such as fluoroscopic examination. **Rationale:** *Self-care supports patient's sense of autonomy.* 6. Explain to patient and family caregiver about the aspiration precautions you are implementing. **Rationale:** *Increases patient cooperation and prepares family caregiver for being able to assist.* 7. Close room door and bedside curtain. **Rationale:** *Provides patient privacy.* 8. Obtain and organize equipment for aspiration prevention. **Rationale:** *Ensures more efficient procedure.* **IMPLEMENTATION** 1\. Perform hand hygiene and have patient or family caregiver (if going to help with feeding) perform hand hygiene. **Rationale:** *Prevents transmission of microorganisms. Educates patient and family caregiver about need to maintain infection control practices.* 2\. Apply clean gloves. Use penlight and tongue blade to gently inspect mouth for pockets of food. **Rationale:** *Pockets of food found inside cheeks occur when patient has difficulty moving food from mouth into pharynx; may lead to aspiration. Patient is usually unaware of pocketing.* 3\. Provide thorough oral hygiene, including brushing tongue, before meal. Remove and dispose of gloves; perform hand hygiene. **Rationale:** *Risk for aspiration pneumonia has been associated with poor oral hygiene.* 4\. Position patient upright (90 degrees) in chair or elevate head of patient's bed to a 90-degree angle or highest position allowed by medical condition during meal. Option: Position patient in the side-lying position if patient cannot have head elevated. **Rationale:** *Position facilitates safe swallowing and enhances esophageal motility* 5\. Have oximeter in position to monitor during feeding. **Rationale:** *Pulse oximetry continues to be used in many agencies in an effort to predict aspiration, but recent research questions its efficacy.* 6\. Provide appropriate thickness of liquids per SLP and RD assessment. Encourage patient to feed self. **Rationale:** *Thin liquids are difficult to control in mouth and pharynx and are more easily aspirated.* 7\. Have patient assume chin-down position. Remind patient to not tilt head backward when eating or while drinking. **Rationale:** *Chin-down position may help reduce aspiration. One study suggests a head-turn-plus-chin-down maneuver may be more successful.* 8\. Adjust the rate of feeding and size of bites to match the patient's tolerance. If patient unable to feed self, place ½ to 1 teaspoon of food on unaffected side of mouth, allowing utensil to touch mouth or tongue. **Rationale:** *Small bites help patient swallow. Provides tactile cue to food being eaten; avoids pocketing of food on weaker side.* 9\. Provide verbal coaching: remind patient to chew and think about swallowing with comments such as the ones that follow: Open your mouth. Feel the food in your mouth. Chew and taste the food. Raise your tongue to the roof of your mouth. Think about swallowing. Close your mouth and swallow. Swallow again. Cough to clear your airway. **Rationale:** *Verbal cueing keeps patient focused on normal swallowing. Positive reinforcement enhances patient's confidence in ability to swallow.* 10\. Avoid mixing foods of different textures in same mouthful. Alternate liquids and bites of food. Refer to RD for next meal if patient has difficulty with particular consistency. **Rationale:** *Gradual increase in types and textures combined with constant monitoring helps patient to eat more safely. Single textures are easier to swallow than multiple textures. Alternating solids with liquids removes food residue in mouth.* 11\. During the meal explain to patient and family caregiver the techniques being used to promote swallowing. **Rationale:** *Enhances patient and family caregiver's ability to use techniques in the home.* 12\. Monitor swallowing and observe for any respiratory difficulty. Observe for throat clearing, coughing, choking, gagging, and drooling of food; suction airway as needed. **Rationale:** *These are indications that suggest dysphagia and thus pose risk for aspiration.* 13\. Minimize distractions, do not talk, and do not rush patient. Allow time for adequate chewing and swallowing. Provide rest periods as needed during meal. **Rationale:** *Environmental distractions and conversations during mealtime increase risk for aspiration. Avoiding fatigue reduces aspiration risk.* **CLINICAL JUDGMENT:** If patient remains stable without difficulty, this is a good time to delegate continued feeding to AP so that you can attend to other patients and assigned priorities. 14\. Use sauces, condiments, and gravies (if part of dysphagia diet) to facilitate cohesive food bolus formation. **Rationale:** *Cohesive food bolus helps to prevent pocketing or small food particles from entering the airway.* 15\. Ask patient to remain sitting upright for at least 30 to 60 minutes after a meal. **Rationale:** *Remaining upright after meals or snacks reduces chance of aspiration by allowing food particles remaining in pharynx to clear.* 16\. Apply gloves. Provide thorough oral hygiene after meal. **Rationale:** *Rigorous oral hygiene reduces plaque and secretions containing bacteria, with studies showing reduction in incidence of pneumonia.* 17\. Return patient's meal tray to appropriate place. Remove and dispose of gloves. **Rationale:** *Reduces spread of microorganisms.* 18\. Be sure patient is comfortable in upright position. **Rationale:** *Promotes patient comfort and safety.* 19\. Place nurse call system in an accessible location within patient's reach. **Rationale:** *Ensures patient can call for assistance if needed.* 20\. Raise side rails (as appropriate) and lower bed to lowest position. Perform hand hygiene. **Rationale:** *Promotes patient safety. Reduces transmission of microorganisms.* **EVALUATION** 1\. Observe patient's ability to swallow food and fluids of various textures and thickness without choking. **Rationale:** *Indicates whether there is ease with swallowing and absence of signs related to aspiration.* 2\. Monitor pulse oximetry readings (if ordered) for high-risk patients during eating. **Rationale:** *Deteriorating oxygen saturation levels may indicate aspiration, but current research questions predictive accuracy of oximetry.* 3\. Monitor patient's intake and output (I&O), calorie count, and food intake. **Rationale:** *Helps to detect malnutrition and dehydration resulting from dysphagia.* 4\. Weigh patient daily or weekly. **Rationale:** *Determines whether weight is stable and reflects nutritional status.* 5\. Observe patient's oral cavity after meal. **Rationale:** *Determines presence of food pockets after meal that has included foods of various textures.* 6\. Use Teach-Back: "We talked about why your husband is at risk to aspirate and choke on his food. Tell me the things to observe for that will tell you if he is having trouble swallowing. What should you do if these things happen during a meal?" Revise your instruction now or develop a plan for revised patient/family caregiver teaching if patient/family caregiver is not able to teach back correctly. **Rationale:** *Teach-back is an evidence-based health literacy intervention that promotes patient engagement, patient safety, adherence, and quality. The goal of teach-back is to ensure that you have explained medical information clearly so that patients and their families understand what you communicated to them.* **[Inserting or Removing a small-bore nasoenteric tube for enteral feedings]** 1\. Verify health care provider's order for type of tube and EN feeding schedule. Also check order to determine whether health care provider wants prokinetic agent (e.g., metoclopramide) given before tube placement. **Rationale:** *Health care provider's order is needed to insert feeding tube. Prokinetic agent given before tube placement may help advance tube (if it is to be advanced into intestine).* 2\. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number) according to agency policy. **Rationale:** *Ensures correct patient. Complies with The Joint Commission standards and improves patient safety* 3\. Review patient's medical history (e.g., for basilar skull fracture, nasal problems, nosebleeds, facial trauma, nasal-facial surgery, deviated septum, anticoagulant therapy, coagulopathy). **Rationale:** *History of these problems requires you to consult with health care provider to change route of nutritional support. Passage of tube intracranially can cause neurological injury*. **CLINICAL JUDGMENT**: *If a patient is at risk for intracranial passage of the tube, avoid the nasal route. Oral placement or placement under medical supervision using fluoroscopic direct visualization is preferable. Insertion of a gastrostomy or jejunostomy tube is another alternative.* 4\. Review medical record to determine patient's risk for developing a medical adhesive--related skin injury (MARSI) using adhesive devices or tape: Age, dehydration, malnutrition, exposure to radiation therapy, underlying chronic conditions (e.g., diabetes, immunosuppression), and edema of extremity. **Rationale:** *These are common risk factors for* MARSI 5\. Assess patient's or family caregiver's health literacy. **Rationale:** *Ensures patient or family caregiver has the capacity to obtain, communicate, process, and understand basic health information*. 6\. Ask patient to describe history of allergies: known type of allergies and normal allergic reaction. Focus on foods and adhesives. Check patient's allergy wristband. **Rationale:** *Communication of patient allergies is essential for safe patient care. If medical adhesive is used to anchor enteral tube to nose, patient is at risk for MARSI* 7\. Assess patient's height, weight, hydration status, electrolyte balance, caloric needs, and I&O. **Rationale:** *Provides baseline information to measure nutritional improvement after enteral feedings.* 8\. Perform hand hygiene. Have patient close each nostril alternately and breathe. Examine each naris for patency and skin breakdown (apply clean gloves if drainage present). If patient previously had NG tube, check for medical device--related pressure injury (MDRPI) (see illustration). **Rationale:** *Reduces transmission of microorganisms. Nares can sometimes be obstructed or irritated, or septal defect or facial fractures may be present. Place tube in more patent naris.* 9\. Perform physical assessment of abdomen (see Chapter 30). Remove and dispose of gloves (if worn). Perform hand hygiene. **Rationale:** *Absent bowel sounds, abdominal pain, tenderness, or distention may indicate medical problem contraindicating feedings. Reduces transmission of microorganisms.* 10\. Assess patient's mental status (ability to cooperate with procedure, level of sedation), presence of cough and gag reflex, ability to swallow, critical illness, and presence of artificial airway. **Rationale:** *These are risk factors for inadvertent tube placement into tracheobronchial tree. Sedation impairs the ability of the patient to clear contents in the pharynx, thus increasing the risk of aspiration.* 11\. Assess patient's knowledge, prior experience with small-bore feeding tube insertion, and feelings about the procedure. **Rationale:** *Reveals need for patient instruction and/or support*. 12\. Assess patient's goals or preferences for how skill is to be performed or what patient expects. **Rationale:** *Allows care to be individualized*. **CLINICAL JUDGMENT**: *Recognize situations in which blind placement of a feeding tube poses an unacceptable risk for placement. Devices designed to detect pulmonary intubation such as CO2 sensors or electromagnetic tracking devices enhance patient safety. Alternatively, to avoid insertion complications from blind placement in high-risk situations, clinicians trained in the use of visualization or imaging techniques should place tubes* **PLANNING** 1\. Explain procedure to patient, including sensations that will be felt during insertion (burning in nasal passages). **Rationale:** *Increases patient's cooperation with procedure and helps lessen anxiety.* 2\. Explain to patient how to communicate during intubation by raising index finger to indicate gagging or discomfort. **Rationale:** *Patient must have a way of communicating to alleviate stress and enhance cooperation.* 3\. Close room door and bedside curtain. **Rationale:** *Provides patient privacy.* 4\. Obtain and organize equipment needed for insertion of small-bore feeding tube at the bedside. **Rationale:** *Ensures more efficient procedure*. **IMPLEMENTATION** 1\. Perform hand hygiene. Stand on same side of bed as naris chosen for insertion and position patient upright in high-Fowler position (unless contraindicated). If patient is comatose, raise head of bed as tolerated in semi-Fowler position with head tipped forward, using a pillow chin to chest. If necessary, have an AP help with positioning of confused or comatose patients. If patient is forced to lie supine, place in reverse Trendelenburg position. **Rationale:** *Reduces transmission of microorganisms. Allows for easier manipulation of tube.* *Fowler position reduces risk of aspiration and promotes effective swallowing. Forward head position helps with closure of airway and passage of tube into esophagus.* 2\. Apply pulse oximeter/capnograph and measure vital signs. Maintain oximetry or capnography continuously. **Rationale:** *Provides baseline for objective assessment of respiratory status during tube insertion and throughout time a tube is in place. Lowered oxygen saturation or increased end-tidal CO2 can indicate tube being misplaced into the lungs or moving out of the stomach into lungs* **CLINICAL JUDGMENT:** If patient has increase in end-tidal carbon dioxide or decrease in oxygen saturation, do not insert tube until you determine patient stability. 3\. Place bath towel over patient's chest. Keep facial tissues within reach. **Rationale:** *Prevents soiling of gown. Insertion of tube frequently produces tearing.* 4\. Determine length of tube to be inserted and mark location with tape or indelible ink. Some tubes have centimeter markings. **Rationale:** *Ensures organized procedure and estimation of the proper length of tube to insert into patient.* a\. ***Option, Adult:*** Measure distance from tip of nose to earlobe to xyphoid process (NEX) of sternum (see illustration). Mark this distance on tube with tape. Most traditional method. Length approximates distance from nose to stomach. Research has shown that this method may be least effective compared with others, although additional research is needed. b\. ***Option, Adult:*** A nose to earlobe to mid-umbilicus (NEMU) method to estimate appropriate NG tube placement has been recommended. **Rationale:** Promotes placement of the tube end holes in or closer to the gastric fluid pool. c\. ***Option, Adult:*** Measure distance from xyphoid process to earlobe to nose (XEN) + 10 cm. **Rationale:** Provides best estimate of NG insertion length (Monica et al., 2019). d\. ***Option, Child:*** Use NEMU option. **Rationale:** Estimates proper length of tube insertion for pediatric patient. e\. Add 20 to 30 cm (8--12 inches) for postpyloric tubes. Length approximates distance from nose to jejunum. **CLINICAL JUDGMENT**: Tip of prepyloric tubes must reach stomach to avoid the risk for pulmonary aspiration, which occurs when tubes end instead in the esophagus. Research has mixed findings regarding the best technique for estimating tube length. Confirmation of placement via x-ray immediately after completed insertion is still needed. 5\. Prepare tube for intubation. NOTE: Do not ice tubes. Iced tube becomes stiff and inflexible, causing trauma to nasal mucosa. a\. Obtain order for stylet tube and check agency policy for trained clinician to insert tube. The practice of inserting a tube requires great care and attention to practice guidelines. **Measure to determine length of tube to insert.** A nursing assistant measures length of nasal tube of a patient sitting on a chair. If tube has guidewire or stylet, inject 10 mL of water from ENFit syringe into tube. Aids in guidewire or stylet removal. Activates lubrication of tube for easier passage and ensures that tube is patent. ENFit devices are not compatible with Luer connection or any other type of small-bore medical connector, thus preventing misadministration of an enteral feeding If using stylet, make certain that it is positioned securely within tube. Inject 10 mL of water from ENFit syringe into tube. Promotes smooth passage of tube into GI tract. Improperly positioned stylet can cause tube to kink or injure patient. Ensures that tube is patent and aids in stylet removal. Once tube insertion is confirmed, have trained clinician remove stylet. 6\. Prepare tube fixation materials (e.g., membrane dressing, tube fixation device, or precut piece of hypoallergenic tape, 10 cm \[4 inches\] long). **Rationale:** Used to secure tubing after insertion. Fixation devices allow tube to float free of nares, thus reducing pressure on nares and preventing medical device--related pressure injury (MDRPI). 7\. Apply clean gloves. **Rationale:** Reduces transmission of microorganisms. 8\. Option: Dip tube with surface lubricant into glass of room-temperature water or apply water-soluble lubricant (see manufacturer directions). **Rationale:** Activates lubricant to facilitate passage of tube into naris and GI tract. 9\. Offer patient a cup of water with straw (if alert and able to swallow). **Rationale:** Patient will be asked to swallow water to facilitate tube passage. 10\. Tube Insertion. Explain next steps and gently i