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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