Nutrition: Enteral and parental feedings

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Enteral vs. Parental Feedings

Enteral
Feeding via the GI Tract through a feeding tube, catheter or stoma.

Parental
Taken into the body in a manner other than through the digestive canal (Intravenously)

Enteral Feedings

Improves nutrition
Preserves GI function
Enhances wound healing
Decreases risk of sepsis

GI TUBES:
Nasogastric Tube
Nasoduodenal Tube
PEG (Percutaneous Endoscopic Gastrostomy)
PEJ (Percutaneous Endoscopic Jejunostomy)

Who needs enteral feedings?

Impaired swallowing (dysphagia)
-CVA, head trauma
-Muscle disorders (MS, ALS...)
Critically ill
-Trauma, burns
-Vents
Unable/Unwilling to eat

Contraindicated for:
Diffuse peritonitis,
Severe pancreatitis,
Intestinal obstruction,
Intractable vomiting or diarrhea,
Paralytic ileus

When to start tube feedings

Enteral feeding should be started with in the first 24-48 hours of admission in critically ill patients who are receiving ventilatory support and who are hemodynamically unstable

Nasogastric Tube Uses:

Gastric Decompression (usually larger bore tube)
-Injury, disease or surgery on GI tract

Feeding (usually a smaller bore tube)
-Usually only used for short term feeding
* 4-6 weeks
* Eventually wears away mucus membranes

Nasoduodenal tubes and nasojejunal tubes

NDTs are used for delivering short-term enteral feedings (usually less than 4 weeks) because they are easy to use and are safer for the patient at risk for aspiration

NJTs are used but are the used least often

Inserting an NG Tube

Position patient sitting upright head straight
-If unable to sit up straight, may position them on their side

Measure from ear lobe, to nose, to xiphoid process - this is how much you will insert - mark the tube

Lubricate the tip of the tube & insert the tube into the nose

Ask patient to breath through mouth and swallow

Continue inserting until the mark is reached

Secure tube with tape or commercial attachment

VERIFY PLACEMENT

While inserting an ng tube....

Never advance against any resistance

Stop if patient is experiencing signs of respiratory distress

Have a "stop signal" in case patient feels unsafe or in distress

Placement verification:Initial verification

X-RAY IS THE MOST ACCURATE WAY TO CHECK PLACEMENT OF AN ENTERAL FEEDING TUBE

SHOULD ALWAYS BE DONE ON INITIAL INSERTION

-Remove the guide wire after
X-ray shows correct placement

Verify placement when.....

Tube first inserted

During your initial nursing assessment

Before administering medication or feed (do so by aspirating for gastric content)

After episodes of coughing, gagging, vomiting

If patient develops s/s of respiratory distress

If you see feeding in the mouth or nose

Something just doesn't look/feel/sound right

ALWAYS HAVE HOB AT 30 degrees or more at all times!!!

AFTER THE INITIAL PLACEMENT:CHECKING VERIFICATION

CHECKING THE INITIAL MARK THAT WAS PLACED ON INSERTION

TESTING ASPIRATED CONTENT FOR PH

ASSESSING CARBON DIOXIDE FOR CAPNOMETRY

CHECK PLACEMENT:
-Before administering feed or meds
-After coughing, vomiting, or gagging
-If patient develops s/s of respiratory distress
-Something just doesn't look or sound right

Checking the pH is not always accurate compared to XRAY
Capnometry tells you you placed it in the lungs or not by detecting CO2.

Placement verification

Is not accepted as EBP, but auscultation is the most frequent way that nurses check placement

Other ways include:
Gastric aspiration and testing the pH (antacids, trauma, blood, continuous feedings and mechanical ventilation could interfere)

New methods:
-Capnography (assessing carbon dioxide levels)
-Cortrak

NEVER ADD DYE TO TUBE FEEDINGS TO DETERMINE PLACEMENT!!!!!!!!!!
This can be toxic to the patient!

Auscultation is most practiced but its not evidence based practice

PEG vs.. PEJ

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY VS PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY

Gastrostomy is a stoma created from the abdominal wall in to the stomach, through which a short feeding tube is inserted

Jejunostomy is used when it is desirable to bypass the stomach, such as with gastric disease, upper
GI obstruction, and abnormal gastric or duodenal emptying

Dual access tubes are sometimes used
___________
PEG is in the stomach
PEJ is in jejunum....It is picked if you have problem with absorption so you bypass the stomach when pt has gastric disease or problem with gastric emptying

PEG vs PEJ

Greater risk of aspiration & GERD with PEG

PEJ also better in impaired gastric motility

Both are placed under fluoroscopy to ensure correct placement

_____
PEG tube is greater risk for aspriration so sometimes they pick PEJ
Peg is in gastrostomy

You need an order from Md to put in Peg or Pej....they have to know many things about pt first like weight, their nutrition, etc.

When putting in feeding, you start slowly!! Like start at 10, not 60 and work up every 1 hour (^ by 10)
Aspirate for residual.
If you get high # of residual the pt is not absorbing the food (150-200)
Return the residual back to the pt cuz electrolytes might be imbalanced.

Tube Feeding initiation

Per MD order or hospital protocol

Initiated slowly to ensure patient tolerates and than increased over time

Check residuals every 4 hours until goal rate is reached

Usually dietician or MD will determine type, rate and method of tube feeding as well as the amount of additional water ("free water") needed.

Types of feedings

Bolus feedings is an intermittent feeding of a specified amount of enteral product at set intervals during a 24 hour period

Continuous feedings is similar to IV therapy in that small amounts are continuously infused over a specified time

Cyclic feedings is the same as continuous except the feedings are stopped for a specific time for bathing, treatment and other activities

Residuals

Check and record the residual volume every 4 hours or per facility policy, by aspirating stomach contents into a syringe.
Residuals of >200, hold tube feedings for 1 hour and recheck.
Contact MD if residuals still elevated
Return or not to return???
-If not returned, may decrease potassium and chloride level
-If returned, may occlude the tube, although less likely if flushed with water
_________
Residuals of >200, hold tube feedings for 1 hour and recheck

If you do return, it may occlude tube, so flush tube with water after feeding or giving med
If you don't return, it may decrease electrolyte K and Cl levels

Complications of enteral nutrition

Refeeding syndrome
Tube misplacement and dislodgement
Abdominal distention and nausea/vomiting
Fluid and electrolyte imbalances
Difficult to determine intolerance because may be due to other factors (meds, disease process)

S/S of Intolerance:
High residuals
-Consider Reglan
N/V
-Elevate head
-Give anti-emetics
Constipation
-Stool softeners, laxatives
Diarrhea
-May be caused by C. Diff or bacterial contamination

Tube Occlusions

FLUSH, FLUSH, FLUSH!
If administering medications/supplements that are very thick, make sure you have adequate water, administer it quickly and flush thoroughly.

Cranberry juice and soda DO NOT fix an occlusion and may even make it worse!

Try warm water first.

Get an order for Viokase which will unblock the tube.

If tube remains occluded, may need replacement.

______
Viokase (tube feeding line) and activase (central line) are used to unblock

Gavage vs Lavage

Gavage:
Aspirate secretion to check tube placement before instilling saline for flush
Gently instill saline into NGT or allow to flow by gravity
Clear BLUE PIGTAIL w/AIR to clear then reinsert anti-reflux valve
Air vent must be clear of secretions to restore proper functioning
___________
Lavage:
Removes unabsorbed poisons from stomach
Activated Charcoal administration to absorb drugs in stomach (pumping the stomach)
Usually done within 60 minutes of ingestion, when possible
Induced vomiting no longer indicated

***Lavage is when your pushing something in.
Gavage is when you take something out. Gavage is garbage and you taking it out

Parental feedings

Nutrition administered outside the GI tract

Intravenous feeding

Used in patients whose GI tract is not functioning or cannot be accessed
_____
Types:
TPN=Total Parental Nutrition
-Nutritionally complete
-Given through CVP or PICC

PPN=peripheral parental nutrition
-Very short-term
-Not as nutritionally complete as TPN
-Given through peripheral IV

What is in Parental nutrition?

Amino Acids
Carbohydrates (10%-35% glucose)
Vitamins
Minerals and trace elements
Electrolytes (individualized based on labs)
Water

Lipids

A commonly used solution in combination with parental nutrition

For patients receiving lipids (fat emulsions) monitor for fat overload syndrome, which symptoms include fever, increased cholesterol, clotting problems, and organ failure

Usually hung for only 12 hours, while TPN or PPN hangs for 24 hours.

Always hang below the filter, as to not clog the filter.

Tpn initiation

Order for TPN determined by MD, pharmacist, and nutritionist based on pt's labs, medical diagnosis, weight, etc.

When hanging TPN, 2 RNs must check composition and rate against written order, cuz you can kill pt with TPN

Nursing and TPN

Compare TPN label and Dr's order - JUST LIKE A MEDICATION ORDER!!!

Verify IV Pump accuracy
TPN Unavailable? Hang D10 until available

Do not attempt to "catch up" by increasing the rate if solution is running "behind"

Monitor daily wt.

Monitor electrolytes and blood sugar

Monitor for s/s electrolyte imbalances

I/O- cuz you can risk pt into fluid overload, like wet lung sounds

Assess for daily weight- fluid gain or loss (.5-1.5 kg. wk) may indicate fluid overload rather than nutritional weight gain.

Assess IV Site- is IV site infected??
INFECTION IS THE MOST COMMON COMPLICATION

Considerations

Use a filter for TPN infusion, but not for lipids

Do not infuse blood or other medications into TPN line

Do not draw blood from TPN line

Do not add anything to TPN/Lipid bottle/bag

Check Daily Electrolytes

Blood glucose is checked usually every 6 hours

Labs that are also monitored are:
Prealbumin (tells you better about nutrition), albumin, triglycerides and cholesterol

Discontinuation of parental nutrition

Must be gradually discontinued and tapered down

If abruptly discontinued, may cause hypoglycemia
_____
Must be tapered cuz can cause hypo or hyper glycemia

Complications of parental nutrition

Fluid imbalance/electrolyte imbalance

Hyperglycemia

Hypoglycemia

In the cardiac or renal patient:

Fluid Overload, CHF may develop

Infection control

Wipe ports prior to use with alcohol swab - scrub the hub

Tube feeding, TPN and PPN formula can only be hung for 24 hours.

Change tubing every 24 hours as well.

If non-closed system only pour in 4 hours worth of feeding at a time to reduce the risk for bacterial growth.

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