Feedings/Obesity/TPN

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Oral feedings--> milk shakes, puddings, eggnogs, Ensure

High calorie supplemental feedings that may be used in the pt whose nutritional intake is deficient.

Tube feeding

Seen in patient who has a functioning GI but is unable to take oral nourishment.

Indications for tube feeding

Protein-calorie malnutrition, anorexia, orofacial fractures, head and neck CA, neurological or psychiatric conditions that prevent oral intake, extensive burns, chemo or radiation.

1. Continuous infusion by pump 2. Intermittent bolus by syringe 3. Cyclic intermittent by infusion pump

Delivery options for tube feedings

Continuous infusion

Most often used tube feeding with critically ill patients and feedings into small intestine.

NG (nasogastric) tube

Most commonly used for SHORT-TERM feeding problems.

GT tube (surgically implanted)

Tube used for feedings for an EXTENDED time (Long-term).

Pour in and gradually let flow in. DO NOT FORCE!! The higher you hold it up, the faster it goes in. Too fast=diarrhea.

Whenever admisitering intermittent bolus by syringe...

Slow the rate.

What should you do if you pull off at least 100 mL of residual?

Polyurethane or silicone--adds to comfort level

Material of feeding tubes.

Decreases the risk of mucosal damange

Why are feeding tubes long, small in diameter, and soft and flexible?

Weighted tips

Allows easier passage of the tube thru the pylorus into the duodenum

decreases the regurgitation of contents into the esophagus and aspiration.

Placement into the intestine....

Comatose and uncooperative pt

Stylet is used for what patients?

To prevent obstruction

Crush meds throughly and dissolve in water before administering thru feeding tube!!!

vomitting or coughing! ALWAYS CHECK RESIDUAL BEFORE ADMINISTERING ANYTHING!!!!!!!!

NG tube can become dislodged by...

Whenever bowel sounds are present (usually 24 hrs after placement)

When can feedings be started with a GT tube?

Tube insertion length

With a GT tube, what should be checked at regular intervals?

Jejunostomy

May be necessary to reduce reflux for patients with chronic reflux

Sitting or lying with HOB elevated 30-45 degrees--prevents aspiration (Leave sitting up for a while after feeding.)

What position should the position be in during tube feedings?

Flushed with 30-60 mL H20--to ensure patency of tube and make sure all formula was administered.

If feedings are intermittent, what is done BEFORE and AFTER each feeding?

CHF, chronic renal failure

For which patients would to not flush the tube with water before and after each feeding?

BEFORE each feeding. Q4H with continuous feedings.

How often should the placement of the feeding tube be checked?

1. Aspiration of stomach contents and check pH using pH paper. *Push contents back in!!!* 2. x-ray

How do you check tube placement?

ph<5

What pH value is indicative of stomach contents?

Room temp to decrease likelyhood of diarrhea

What temperature should the formula be when administered? Why?

This is a sign of intolerance. The next feeding should be held for 1 hr then residual should be rechecked.

If the nurse aspirates >100 mL of stomach contents what should the nurse do?

damage the mucosa... DO NOT FORCE!!!

Applying pressure to force the feeding could....

Weigh daily and I&Os

General nursing considerations for pt with feeding tube.

8 hrs

Discard feedings that have been hanging for longer than ___ to minimize bacterial growth and to prevent administration of contaminated feeding.

Date and time of start

Feedings should be labeled with?

Complication of Tube Feedings

Vomitting, aspiration, diarrhea, constipation, and dehydration.

Obesity

Most common nutritional problem.

Increases with age, woman, African American or Hispanic

Higher prevalance of obesity

1. BMI 2. Waist-to-hip Ratio--increases c age and excessive weight (waist measurement divided by hip measurement)

2 ways to define obesity

Men >1.0 and Women >0.8

Waist-to-hip measurement that indicates obesity

Consuming more food than is required

How does adipose tissue form?

Early onset obesity

Adipose tissue mass is distributed universally over entire body.

Adult onset obesity

Adipose tissue mass is centrally distributed.

1. android (apple) --worse on heart 2. gynoid (pear) --varicose veins

How fat is distributed on the body frame can affect the severity of health risk--2 classifications

Android (apple)

Upper body fat pattern

Gynoid (pear)

Greater peripheral distribution of fat

Android pattern

Android or Gynoid??--Higher risk for CAD, HTN, D/O of glucose intolerance, hyperlipidemia.

Shrink the size of the cells!!

Diet does NOT decrease the number of fat adipocytes. Diet....

Complications of obesity

Varicose veins and venous leg ulcers b/c of increase back pressure on venous return. Heart size increases, HTN, Type 2 diabetes, Hyperglycemia, Gallstone formation, Rise in cholesterol and triglyceride levels--->CAD, Excessive weight on weight-bearing joints (hips and knees)-->osteoarthritis. Menstrual irregularities, infertility, endometrial CA, fatty liver infiltration. Life expectency shortened. Emotional and social problems-->discrimination, difficult to obtain job, social acceptance, and membership in organizations. Choice of clothing limited. Poor self-esteem and body image.

Excess calorie intake

Overwhelming majority of obese patients has PRIMARY obesity, which is?

Secondary

Type of obesity that results from congenital anomalies, chromosomal anomolies, and metabolic problems.

Determining whether an physical conditions are present

First step in treating obesity

1. BMI (skin folds with calipers) 2. Weigh-to-height Chart 3. Direct observation

Techniques for determining obesity

Restricted food intake

Cornerstone for any weight loss or maintenance program?

Foods from the basic food groups

Good weight loss program contains what foods?

Low calorie diet

800 to 1200 calories

Very low calorie diet

<800 calories

Restrict dietary intake so it is below energy requirement

Only effective method of treating primary obesity.

Well BALANCED, LOW calorie diet

Essentail part of weight loss

Other therapy for obesity

Motivation, exercise, behavior-cognitive therapy

Appetite suppressant drugs -- will NOT cure!!!

Palpitations, tachycardia, over stimulation, restlessness, dizziness, weakness, and fatigue

Criteria considered for surgical tx of obesity

1. Gross obese for 5 years 2. FAILURE to lose weight with OTHER forms 3. Body weight 100% above ideal for age, gender, and height 4. NO serious ENDOCRINE problems 5. ABSENCE of MED PROBS (liver disease, CV or pulmonary diseae, alcholism) 6. Psychiatric and social stability AND willingness to cooperate with longterm follow up

Liposuction

Surgery done for cosmetic reasons, not for weight reduction

Older adult-- skin is less elastic and will not accomadate to new shape

Liposuction is not recommended for who?

1. Vertical banded gastroplasty 2. Gastric bypass 3. Circumgastric banding

3 types of gastrointestinal surgies for obesity

Vertical banded gastroplasty

Vertical line of staples to create small stomach pouch. Band is connected to provide an outlet to the small intestine.

Gastric bypass

Stomach, duodenum, and part of jejunum are bypassed so fewer calories are absorbed.

Circumgastric banding

Limits stomach size by placing inflatable band around fundus of the stomach. The band can be inflated thru a SQ port to change the size of stomach.

FIRST year. (Weight stabilized after 18 mths)

With gastric bypass surgery, most of the weight is lose when?

Dumping syndrome

Complication of gastric bypass surgery

Dumping syndrome (cold sweat, diarrhea)

When gastric contents empty too rapidly into the small intestine, overwhelming its ability to digest nutrients.

iron or calcium deficiency---> lifelong supplementation

Dumping syndrom can cause...

Vertical banded gastroplasty

Frequently used to reduce weight loss in the morbidly obese person.

Problems of vertical banded gastroplasty

Intractable vomitting from too rapid intake of solids, distention of the wall of the proximal pouch, rupture of staple line, and erosion of band in stomach.

High protein, low carbs fat and roughage (high carbs=diarrhea)

For the obese patient after surgery, the diet should consists of?

Post op interventions

Wound healing, TCDB, Spirometer Q2H, Early ambulation (TEDS, heparin, ROM), NG tube, PCA, HOB 30 degree angle.

Total Parenteral Nutrition

Used when the GI system CANNOT be used for ingestion, digestion, and absorption of essential nutrients.

TPN

Goal of ___ is to meet pt's nutritional needs and allow for growth of new body tissue.

170 calories/L and NO protein

Regular IV solutions (D5W or D5LR) contain

1200-1500 calories/day

The normal adult requires how many calories/day to carry out normal physiological functions.

Glucose, proteins, vitamins, minerals, and electrolytes

TPN contains

IV route (Central line or PICC line)

How is TPN administered?

Indications for TPN

Chronic diarrhea and vomitting, complicated surgery, GI obstruction, malnutrition, pancreatitis, sever malabsorption, severe anorexia nervosa.

Q 30 min to 1 hr

How often should the amount infused and rate be checked with TPN?

So infusion rate is maintained---alarm sounds if tubing becomes obstructed.

USE INFUSION PUMP WITH TPN!!!!

Nurse

Who's responsibility is it to check the solution for cloudy appearance and date/time?

24 hrs

How long can a TPN solution hang before being discarded?

Increased blood glucose levels--check q4-6 hrs (Hyperglycemia is a complication of TPN so solution is infused and gradually increased over 24-48 hrs-->allow pt to adapt to inc amount of glucose)

In the beginning of TPN therapy, what is expected?

Nursing management for TPN

VS Q4-8Hrs, daily weight, blood levels--glucose, electrolytes, and CBC, Dressing change (daily to once a week)

Complication of TPN

Infections, metabolic probs (hyperglycemia, hyperlipidemia), insertion probs (air embolism, pneumothorax, hemorrhage, thrombosis of great vein, phlebitis, dislodgement).

BP and blood drawing

Do not use arm in which catheter was inserted for what?

24 hrs

TPN: Change filters and tubing q ____ because TPN is excellent for microbial growth.

PICC

Placement is done under sterile conditions at baseline of upper arm circumference using the cephallic or basillic vein. Tourniquet placed around upper arm near axilla, pt in supine postion with arm straight and at 90 degree angle. Local anesthetic used at insertion site. Chest xray to confirm placement.

Central line

Placement performed by physician using subclavian vein under strict aseptic conditions. Standard isotonic solution infused first until xray confirms proper placement of the tip in the superior vena cava. Covered with sterile dressing.

Pharmacist

TPN solutions are prepared by ___ under strict aseptic technique.

1. Nutrient content 2. All additives 3. Time mixed 4. Date and time of expiration

TPN label includes...

24 hrs (must be refrigerated until 30 min before use)

TPN solutions are good for ____.

Flow rate gradually decreased for 4-6 hours and increase oral intake.

You must wean patients off TPN.

Signs of infection

Local manifestions--- erythematic, tenderness, excudate at cath insertion site. Systemic--chills, fever, N/V, malaise

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