Transcript HERE

Basic procedures in healthcare 1
(SOL / VCA81)
TOPICS:
13a) Nutrition and feeding of patients
13b) Dietary system in the Czech Republic
13c) Parenteral and enteral nutrition
13d) The introduction of nasogastric tube (NGT)
13a) Nutrition and feeding of patients
 term explanation
 food and its components
 factors influencing nutrition
 pathologies of nutrition
 principles when serving food
 feeding of bedridden patients
13a) Nutrition and feeding of patients
Nutrition
 nutrition = food intake and processing of nutrients,
 nutrients = substances which participate in the metabolism,
- basic – proteins, fats, sugars,
- additives – vitamins, minerals, water.
*
13a) Nutrition and feeding of patients
Food and its components
Proteins:
 they disintegrate into amino acids by digestion,
 protein supply 10-15% of all the necessary calories,
 legumes, almonds, walnuts, pork, veal, chicken meat.
*
13a) Nutrition and feeding of patients
Fats:
 compounds of fatty acids
and glycerol,
 energy source,
 bearers of fat-soluble vitamins,
 daily consumption of not more THAN 66g*,
 prefer vegetable fats of animal fats,
 saturated fatty acids - sunflower oil, soya, wheat germ, nuts,
olives.
* daily dose for an adult
*
13a) Nutrition and feeding of patients
Carbohydrates:
 the main energy source,
 supply up to 60% of total calories,
 daily consumption 275 - 375g*.
*
Division:
 monosaccharides – glucose, fructose (fruit, honey… ),
 disaccharides – sucrose, lactose, maltose (banana, pineapple,
milk of mammals, cereals),
 polysaccharides – starch, cellulose - plant fiber (seeds, fruits,
vegetables, whole grains.
* daily dose for an adult
13a) Nutrition and feeding of patients
Vitamins:
 organic substances needed in very small quantities,
- water-soluble – B, C,
- fat-soluble – A, D, E, K.
*
13a) Nutrition and feeding of patients
Minerals:
 involved in the composition
of our organism,
 78 elements is in the body
(21 most important).
Water:
*
 creates 70-75 % of our body,
 daily water consumption approx. 2,5-3 l,
 best - pure water, mineral water, tea, fruit juices,
 expenditure – breathing (0,5l), skin (0,6l), urine (1,5l), faecal (0,15l).
13a) Nutrition and feeding of patients
Factors influencing nutrition
Biological factors:
 the function of the digestive system (disturbed function of the
digestive system),
 age, gender,
 health condition (diseases of the oral cavity, dental status… ).
Psychological factors:
 stress, psychosomatic conditions (anorexia, bulimia).
Social factors:
 culture, the environment, customs, economic conditions,
the natural environment…
13a) Nutrition and feeding of patients
Pathologies of nutrition
 anorexia – loss of appetite,
 cachexia – pathological emaciation,
 refusing food – active form of anorexia,
 hyperorexia – excessive feel of hunger,
 special appetite – e.g. pregnancy, stress,
 dysphagia – disorder of swallowing,
 dyspepsia – upper X lower dyspeptic syndrome + a summary
of symptoms (belching, heartburn, nausea… ),
 anorexia nervosa – eating disorder, deliberate reduction in body weight,
 bulimia nervosa – eating disorder, recurrent episodes of binge eating
involving the deliberate vomiting,
 alnutrition, marasmus, obesity, obesity, overweight, and others.
*
13a) Nutrition and feeding of patients
Principles when serving food:
 each patient receives the right diet,
 the food is hot and suitably prepared,
 regular meals (5 times a day),
 we supply plenty of fluids,
 capable patients are able to eat
in the dinning hall or at a table
in the room,
 patients who can not leave bed, eat in it.
*
13a) Nutrition and feeding of patients
Feeding of lying (infirm) patients:
 the patient assumes the position semi sitting,
 we tie a bib or cloth around the neck,
 we move the dining table and serve food,
 we fed slowly, patiently,
we supply enough fluids.
After the meal:
 we wipe the patient's mouth,
 we clean dishes,
 we adjust the position of the patient and a bed,
 if the patient has dentures, we take it out and clean.
*
13b) Dietary system in the Czech
Republic
 hospital diet system
 dietary system in the Czech Republic
13b) Dietary system in the Czech
Republic
Hospital diet system
 given by directive,
 nutritional questionnaire on admission of the patient,
 therapeutic diets,
 special diets – described, addition,
 delivering meals to the treatment unit via tablet system.
*
13b) Dietary system in the Czech
Republic

1B mushy saving

9/S diabetic saving (225g carbohydrates)

1 ground saving

9B diabetic with milk protein reduction

2 saving

9W diabetic Warfarin (225g carbohydrates)

4 with fat reduction

3 rational

4S with strict fat reduction

3X rational special

4/SP with strict fat reduction + animal
protein

11/P rational reducing flatulence

4/AL when food allergy

12 toddler

12K infant

13 children diet

GER geriatric

GER/9 geriatric diabetic

VEG vegetarian

5 with reduction of residue

6 with protein reduction

6/9 with protein reduction, diabetic

8 reduction (175g carbohydrates)

9 diabetic
13c) Parenteral and enteral nutrition
 term explanation
 indications for enteral nutrition
 dividing of products for enteral nutrition
 contraindications of enteral nutrition
 method of enteral feeding
 indications for parenteral nutrition
 way of parenteral nutrition administration
 products for parenteral nutrition
 contraindications of parenteral nutrition
13c) Parenteral and enteral nutrition
Artificial nutrition
- indicated in patients who are not able to eat for a longer period,
or in patients suffering from malnutrition.
Enteral nutrition:
 administration of nutritional substrates to the stomach or intestines
to provide nutrition (sipping, probe nutrition – NGT, NJT, PEG,
PEJ),
 it uses a natural way of nutrients delivery.
Parenteral nutrition:
 administration of nutritional substrates to systemic circulation
(solutions applied i. v.),
 bypasses the liver, intestines.
13c) Parenteral and enteral nutrition
Enteral nutrition - indication:
 injury, surgery and disease of oropharyngeal and oesophageal
areas,
 diseases surgery on the digestive tract in area of the stomach
and small intestine,
 disorders of eating mechanism (stroke),
 conditions requiring intensive care (postoperative period,
craniocerebral injury),
 refeeding treatment in malnutrition,
 repeated vomiting (prevention of aspiration),
 loss of appetite (geriatric, psychiatric patients).
13c) Parenteral and enteral nutrition
Dividing products by content 1
Full-fledged polymeric:
 it contains protein in the form of polymer,
 partially digested,
 Nutrison Standard, Nutrison Energy, Multifibre, Fresubin.
Full-fledged oligomeric:
 protein is in the form of oligopeptide,
 chemically defined diets,
 contains completely resolved basic components of nutrition.
13c) Parenteral and enteral nutrition
Dividing products by content 2
Synthetic:
 amino acids.
Modified types of nutrition:
 enriched with nutrients with therapeutic effect.
13c) Parenteral and enteral nutrition
Contraindications of enteral nutrition:
 in the acute phase of disease,
 acute abdomen emergency,
 complete bowel obstruction (ileus),
 intestinal fistula,
 haemorrhage GIT,
 relative contraindications: inability to secure the entry into the
GIT (burns, multiple trauma, uncooperative patient).
13c) Parenteral and enteral nutrition
Methods for administration of enteral nutrition
Bolus application:
 using Janett syringe,
 total amount of one portion 250 - 400 ml,
 only the stomach, it can not be administered into the intestine.
Intermittent:
 one dose is divided in partial doses,
 it served intermittently throughout the day with a night break
(e. g. in 2h or 3h with a break from 24:00 to 6:00).
13c) Parenteral and enteral nutrition
Methods for administration of enteral nutrition
Continual:
 feeding from a bottle or bag,
 with enteral pump,
 speed of nutrition mostly determined in ml/hr (constant speed),
 20 hrs without interruption, the night pause,
 a special, manufacturer-recommended bags belong to the enteral
pumps.
13c) Parenteral and enteral nutrition
Parenteral nutrition - indication:
 impossibility of using GIT,
 severe diarrhoea or vomiting,
 ileus,
 liver failure.
 intestinal fistula,
 acute abdomen emergency,
 extensive intestinal surgery,
 short bowel syndrome,
 bleeding in GIT,
 acute pancreatitis,
 idiopathic bowel inflammation,
Zdroj: http://www.rxkinetics.com/tpntutorial/fig_1_4.gif; 18.6.2015
13c) Parenteral and enteral nutrition
Way of administration:
a) Into a peripheral vein
 only short-term nutritional support,
 the risk of phlebitis,
 the solution for hydration correction
(water, electrolytes),
 adjustment of energy intake – 5% G,
 adding vitamins,
 adding of proteins.
*
13c) Parenteral and enteral nutrition
b) Into a central vein
 all other solutions which cannot be
injected into PVC,
 long-term nutritional support,
 possibility to administer a concentrated
solution in a small volume without the risk
of phlebitis,
 most cannulation v. subclavian,
v. jugularis, end of the catheter is placed
into the superior vena cava or the
implantation of venous port.
Zdroj:
http://www.stezen.cz/html/stezen/casopis/2014/01/clanky
/obr/clanek_06_3.jpg; 18.6.2015
13c) Parenteral and enteral nutrition
Products of parental nutrition
System multi-bottle
System all-in-one
 administering of nourishment from  all components of nutrition in
several bottles at the same time,
one bag,
 ↓ demands for nursing staff,
 separetly amino acids, lipids,
glucose,
 better utilization of nutrients,
 the possibility to change the
composition, add pharmaceuticals,
 ↓ the risk of entry of infection,
 more difficult manipulation,
 ↑ price,
 higher risk of infection,
 uneven nutrient intake.
 more comfortable,
 you can not change the
composition of the bag.
Source: author´s pic
13c) Parenteral and enteral nutrition
All in one
Clinimix
- 2-chamber bag, 1 chamber amino acid+ electrolytes,
2 chamber glucose + calcium,
- application into the CVC.
Nutriflex lipid peri
- 3-chamber bag,
- upper left chamber – glucose,
- upper right chamber – fat emulsion,
- lower chamber – amino acid,
- applications to the peripheral venous system.
*
All in one bag
13c) Parenteral and enteral nutrition
Contraindications for parenteral nutrition
 sufficiently functional digestive tract,
 terminal disease status,
 rejection of nutritional support from the patient,
 there are no reasons on which the parenteral nutrition is clearly
indicated.
*
13d) The introduction
of nasogastric tube (NGT)
 probes for enteral nutrition
 tools for NGT introduction
 position when NGT introduction
 procedure when NGT introduction
 control of NGT introduction
 videos (introduction of NGT, serving meals through NGT)
 contraindications of NGT introduction
13d) The introduction of NGT
Probes for enteral nutrition
 different sizes, different average,
 NGT, NJT, gastrostomy probe (PEG), jejunostomy probe (PEJ),
 the average is color-coded (20 - yellow, 18 - red, 16 - orange,
14 - green, 12 - white),
 polyurethane, silicone rubber,
 length 75 – 130 cm.
13d) The introduction of NGT
Probes of enteral nutrition
Zdroj:http://i00.i.aliimg.com/img/pb/370/929/717/717929370_735.JPG; 18.6.2015
Zdroj:http://g02.s.alicdn.com/kf/HTB1gHkRFFXXXXc4XVXXq6xXFXXXn/200683810/HTB1gHk
RFFXXXXc4XVXXq6xXFXXXn.jpg; 18.6.2015
PEG passage through the abdominal wall
13d) The introduction of NGT
Tools:
 probe of appropriate size if possible frozen,
 local anaesthetic (Mesocain gel), Xylocain spray, nasal drops,
 disposable gloves,
 Janett syringe 50ml,
 stethoscope,
 adhesive plaster to fix NGT,
 tea or water,
 swabs, vomit bowl, oral scoop,
 collecting bag for NGT connection,
 or peg to close NGT.
13d) The introduction of NGT
Position for introduction

When the patient is conscious – semi sitting - sitting, the
patient sits by himself / herself, we incite the patient to actively
cooperate (e. g. when introducing the patient swallows – easier
introducing of NGT, fluid support).

When the patient is unconscious – we position the patient,
if his health condition allows it (beware of the head and spine
injuries).
13d) The introduction of NGT
NGT introduction:
 if possible, position the patient to the semi sitting position with
slightly bent head on aside (Fowler´s position),
 wash your hands and put disposable gloves on,
 ask patient if he / she did not have any nose injury in the past
or if he / she is not after the nasal septum surgery,
 check the loose of nostrils,
 measure length of NGT from the end of the nose to the earlobe
until the end of the sternum,
 put Mesocain gel on NGT, apply nasal drops into the nasal
passages,
13d) The introduction of NGT
 patient, if possible, ask for swallowing and quickly introduce NGT
into the stomach every time he / she swallows,
 when nausea stop introducing NGT,
 check the position after introducing NGT deep enough,
 fix NGT with plaster to the nose,
 close the end of the probe using pin or connect the collection
bag,
 regularly perform oral hygiene and nursing care (prevention of
pressure ulcers),
 if the patient is unconscious and NGT introducing is difficult, it is
possible to use Magill forceps and laryngoscope.
13d) The introduction of NGT
NGT introduction
13d) The introduction of NGT
Control of NGT introduction:
 aspiration of gastric contents with Janett syringe,
 listening with a stethoscope while injection the air with Janett
syringe into the stomach – audible gurgle,
 dyspnoea of the patient– sing of introduction into the lungs
(if the patient is conscious),
 NGT position can be checked in extreme cases by X-ray.
After the introduction of NGT:
 disposable tools clean up into a container which is intended for
contaminated waste, and disinfect the other tools or sterilize
according to the department order.
13d) The introduction of NGT
 The introduction of nasogastric tube (NGT)
https://www.youtube.com/watch?v=jP0WI9TNxxc
 Feeding through NGT
https://www.youtube.com/watch?v=HF4lGo6AVLw
13d) The introduction of NGT
Contraindications of NGT introduction:
 difficult introduction (uncooperative patient),
 fear and anxiety of the patient,
 intolerance of the tube as a foreign subject,
 incorrect introduction,
 perforation of the oesophagus, stomach, or respiratory,
 kinking of the tube,
 NGT is clogged with gastric contents,
 aspirations while introducing,
 epistaxis.
*
Revision
 Name the fat-soluble vitamins.
 What factors do affect nutrition?
 Diet 9, 5, 1B, GER?
 What is enteral nutrition? What are its advantages?
 What will you do if your patient starts vomit during NGT
introducing?
 How will you find out that you introduced NGT into the lung
when the patient is unconscious?
 List the ways of enteral feeding.
 Describe the introduction of NGT.
 Why does the nutrition applied through NJT or PEJ have to be
pharmaceutically prepared in advanced?
Reference:
 LF a FZV UP Olomouc, klinické téma, umělá výživa [online]. 2015.
[cit.8.6.2015]. Dostupné z http://pfyziollfup.upol.cz/castwiki2/?p=3303
 MIKŠOVÁ, Zdeňka, Marie FROŇKOVÁ, Renáta HERNOVÁ a Marie
ZAJÍČKOVÁ, kapitoly z ošetřovatelské péče 1. Aktualiz. a dopl. vyd.
Praha: Grada, 2006, 90s. ISBN 80-247-1442-6
 Multimediální trenažer plánování ošetřovatelské péče, vyuka-terapie,
enterální výživa, parenterální výživa [online] 2015
[cit.9.6.2015].dostupné z: http://ose.zshk.cz/vyuka/terapie.aspx
 VELKÝ LÉKAŘSKÝ SLOVNÍK [online]. 2015 [cit. 2015-06-8].
Dostupné z: www.lekarske.slovniky.cz
 PICTURES * (if it is not listed differently): pinterest.com, google.com.
Key words: „ok“, „not ok“, „nasogastric tube“…)