Transcript Change tubing q 24 hrs

Nutrition
B260: Fundamentals of Nursing
Nursing Knowledge Base
• The five components of a nutrition assessment:
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Screening for malnutrition for risk factors
Anthropometry
BMI
Labs and tests
Dietary history
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Nursing Knowledge Base
• Factors influencing nutrition
– Environmental factors
– Developmental needs
• Infants through school age
• Adolescents
• Young and middle adults
• Older adults
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Nursing Knowledge Base
• Alternative Food Patterns
– Based on religion, cultural background,
ethics, health beliefs, and preference
– Vegetarian diet consists predominantly
of plant foods
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Assessment
• Screening a patient is a quick method of identifying
malnutrition or risk of malnutrition using sample tools:
– Height
– Weight
– Weight change
– Primary diagnosis
– Comorbidities
– Screening tools (3 used in practice)
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Assessment
• Assess patients for malnutrition
– Conditions that interfere with their ability to ingest, digest,
or absorb adequate nutrients.
– Congenital anomalies and surgical revisions of the GI tract
– Only IV therapy
– Chronic diseases or increased metabolic requirements
– Infants and older adults are at great risk
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Assessment
– An ideal body weight (IBW) provides an estimate of
what a person should weigh.
– Body mass index (BMI) measures weight corrected for
height and serves as an alternative to traditional
height-weight relationships.
• Laboratory
– Albumin: 3.5-5.0 g/dL (half life 21 days)
– Transferrin and total iron-binding capacity (TIBC)
– Hemoglobin (12-18%)
– Prealbumin (half life 1.9 days)
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IBW Chart and BMI Chart
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Assessment
• Dietary and health history
– Health status; age; cultural background; religious food
patterns; socioeconomic status; personal food
preferences; psychological factors; use of alcohol or
illegal drugs; use of vitamin, mineral, or herbal
supplements; prescription or over-the-counter (OTC)
drugs; and the patient’s general nutrition knowledge
• Physical examination
• Dysphagia (difficulty swallowing)
– 4 Screening tools
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Dysphagia
• Dysphagia refers to difficulty swallowing.
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Nursing Diagnosis
Risk for Aspiration r/t impaired swallowing
Outcome: Patient will maintain patent airway and clear
lung sounds.
Nursing Interventions
1. Monitor for s/s of difficulty in swallowing
1. 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.
2. Abnormal gag, delayed swallowing, incomplete oral
clearance or pocketing, regurgitation, pharyngeal
pooling, delayed or absent trigger or swallow, and
inability to speak consistently
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Nursing Diagnosis
Risk for Aspiration r/t impaired swallowing
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Monitor Respiratory rate, depth, and effort
Auscultate lung sounds q 4 hrs
Monitor bowel sounds q 4 hrs
Take VS q 4 hrs, esp. temp
Feed slowly with small bites and allow time for
chewing and swallowing
6. Place food on strong side of mouth
7. Have patient sit upright when eating and keep HOB 3045 degrees for an hour after eating
8. Encourage patient to use chin tuck when swallowing
9. Provide rest periods
10. Consult HCP for speech consult for swallow study
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Acute Care Considerations
• The nutritional care of acutely ill patients requires monitoring.
– Patients are interrupted at meal time
– NPO status
– Poor appetites
– Fatigued or feel uncomfortable
– Patient who are NPO and receive only IV fluids for more
than 4-7 days are at nutritional risk.
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Diets Orders
Box 44-10 pg 1017
• Clear liquids: broth, coffee, tea, clear soda & juice,
jello, popsicle
• Full: above + smooth dairy
• Pureed: above + scrambled eggs, pureed meat –
vegetables –fruits, mashed potatoes
• Mechanical soft: above + diced meats, flaked fish,
cottage cheese, rice, potatoes, etc.
• Soft/low residue: low fiber foods, pasta, tender
meat, canned fruits/vegetables
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Nutrition: Types of Diets
• High fiber: fresh fruit, steamed vegetables, bran,
oatmeal, dried fruit
• Low sodium: 4 g, 2 g, 1 g
• Low cholesterol: 300 mg/day
• Diabetic: usually 1800 cal/day
• Regular: no restrictions
Nursing Diagnosis
Imbalanced Nutrition: less than body requirements r/t poor
appetite
Outcome: Patient will eat 50% of breakfast, lunch and dinner.
Nursing Interventions
1. Monitor food intake; recorded percentages of
served food that is eaten
2. Monitor patient ability to eat (time involved, motor
skills, visual acuity, and ability to swallow)
3. Offer small frequent meals
4. Assist with ordering meals, encouraging familiar
foods
5. Avoid interruptions during mealtimes
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Nursing Diagnosis
Imbalanced Nutrition: less than body requirements r/t poor
appetite
6. Provide a calm, peaceful, pain free, odor free
environment
7. Provide social interaction by encouraging family to
visit during meal times.
8. Encourage or provide oral care prior to meal time
9. Provide rest periods before meals
10. Consult with HCP for a Dietary consult
11. Teach the importance of having good nutrition during
the time of an illness.
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Enteral Tube Feedings
• Enteral nutrition (EN) provides nutrients into
the GI tract.
• Feedings are provided for patients who can not
swallow and have a functioning GI tract.
• Feedings can be delivered through a nasogastric
(NGT), jejunal (JT) or gastric tube (GT).
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Peg Tube, J-Tube, G-Tube
Enteral Tube Feedings
Procedure:
• Start at full strength
• Slow rate
• Increase every 8-12 hours as ordered
• Assess for signs of intolerance
• High gastric residuals (G-Tube only), nausea,
cramping, vomiting and diarrhea
• Assess for complications
• Aspiration, Diarrhea, Bacterial contamination,
Tube occlusion, delayed gastric emptying
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Nursing Diagnosis
Risk for Aspiration r/t NGT feeding
Outcome: Patient will maintain patent airway and clear lung
sounds.
Nursing Interventions
1. Determine if patient is at high risk for aspiration:
coughing, hx of GERD, nasotracheal suction, an artificial
airway, decreased LOC, and lying flat.
2. Keep HOB up to 30-45 degrees at all times
3. Measure gastric residual volumes every 4-6 hrs.
– 250 ml or more on 2 consecutive assessments:
delayed gastric emptying or if 500 ml on assessment
– Discuss follow up with HCP
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Nursing Diagnosis
Risk for Aspiration r/t NGT feeding
4. Stop feedings if aspiration occurs
5. Administer metoclopramide (Reglan) if
ordered
6. Monitor for nausea, vomiting, cramping and
diarrhea and tube occlusion.
7. Increase rate per order
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Tube Placement
• The most reliable method for verification of
placement of small-bore feeding tubes is xray film examination.
• Check pH of gastric aspirate, < 4
• Observe aspirate color
• Do not use auscultation method
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Tube Placement
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Feedings
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Total Parenteral Nutrition
• Total Parenteral nutrition (TPN) is a form of specialized
nutrition support in which nutrients are provided
intravenously.
• A basic TPN formula is a combination of amino acids,
hypertonic dextrose (10-50%), electrolytes, vitamins, and
trace elements.
• Fat emulsions: provides calories and fatty acids
– Delivered through
• Central venous catheter
• PICC line
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Parenteral Nutrition
• If using a CVC that has multiple lumens, use a port
that is exclusively dedicated for the TPN. Label it!
• Verify the HCP’s order
• Inspect the solution for particulate matter
• Always use an infusion pump
• First 24-48 hrs: delivers 50% of estimated needs and
then rate has will be increased
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Parenteral Nutrition: Complications
• Catheter-related Problems
– Pneumonthorax
• Sudden sharp chest pain, dyspnea, and coughing
• Monitor for 24 hrs
– Air embolus
• Occurs during insertion of the catheter or when
changing the tubing or cap.
• Turn pt to left side and have pt perform a Valsalva
maneuver (hold breath and bear down during catheter
insertion to help prevent air embolus
• Keep IV system closed
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Parenteral Nutrition: Complications
• Catheter-related Problems
– Catheter occlusion
• If sluggish or no flow, stop infusion and flush with NS or
heparin (per protocol).
• Attempt to aspirate clot or follow protocol for thrombolytic
agent (urokinase)
– Sepsis
• Fever, chills, or glucose intolerance and positive blood
culture
• Change tubing q 24 hrs
• Hang bag for only 24 hr; lipids 12 hrs
• Check to see if solution needs a filter
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Parenteral Nutrition: Complications
• Metabolic alterations
– Electrolyte and mineral imbalances
– Hyperglycemia
• Thirst, HA, lethargy, increased urination.
• Monitor BS q 6 hrs
• Give insulin
– Hypoglycemia
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Diaphoresis, shakiness, confusion, loss of consciousness
Do not abruptly discontinue TPN
Taper rate
Give IV bolus of dextrose
– Dehydration
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Nursing Diagnoses
1. Risk for Aspiration r/t impaired swallowing
2. Imbalanced Nutrition: less than body
requirements r/t poor appetite
3. Risk for Aspiration r/t NGT feeding
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