Oral feedings--> milk shakes, puddings, eggnogs, Ensure
High calorie supplemental feedings that may be used in the pt whose nutritional intake is deficient.
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
Most often used tube feeding with critically ill patients and feedings into small intestine.
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...
Decreases the risk of mucosal damange
Why are feeding tubes long, small in diameter, and soft and flexible?
decreases the regurgitation of contents into the esophagus and aspiration.
Placement into the intestine....
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?
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?
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?
Discard feedings that have been hanging for longer than ___ to minimize bacterial growth and to prevent administration of contaminated feeding.
1. BMI 2. Waist-to-hip Ratio--increases c age and excessive weight (waist measurement divided by hip measurement)
2 ways to define obesity
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 or Gynoid??--Higher risk for CAD, HTN, D/O of glucose intolerance, hyperlipidemia.
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.
Type of obesity that results from congenital anomalies, chromosomal anomolies, and metabolic problems.
1. BMI (skin folds with calipers) 2. Weigh-to-height Chart 3. Direct observation
Techniques for determining obesity
Restrict dietary intake so it is below energy requirement
Only effective method of treating primary obesity.
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
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.
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 (cold sweat, diarrhea)
When gastric contents empty too rapidly into the small intestine, overwhelming its ability to digest nutrients.
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.
The normal adult requires how many calories/day to carry out normal physiological functions.
Indications for TPN
Chronic diarrhea and vomitting, complicated surgery, GI obstruction, malnutrition, pancreatitis, sever malabsorption, severe anorexia nervosa.
So infusion rate is maintained---alarm sounds if tubing becomes obstructed.
USE INFUSION PUMP WITH TPN!!!!
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).
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.
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.
1. Nutrient content 2. All additives 3. Time mixed 4. Date and time of expiration
TPN label includes...
Flow rate gradually decreased for 4-6 hours and increase oral intake.
You must wean patients off TPN.