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Chapter 40:
Patient Management:
Gastrointestinal System
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Introduction
• Foods consumed support metabolism. Two types of metabolism:
–
Anabolism: build up and repair
–
Catabolism: break down and create energy
• Glucose is the primary energy fuel
–
Not readily storable by most organs
–
Must be extracted from blood
–
Excess is stored as glycogen or triglycerides
–
Glucose can be changed to fatty acids, but the reverse cannot be
done. Fatty acids can be used as energy fuel, but they produce
ketones.
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Ketone Use
• Glucose is primary energy fuel
• During starvation, the body can use fatty acids as fuel
• The end product of fatty acid use is ketones
• Excess ketones wind up in the blood if they aren’t used
• This is called ketoacidosis
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Role of Pancreas
• Glycogenolysis is glycogen breakdown
– Medullary control
– Role of glucagon and cortisol
• Gluconeogenesis is glucose production from proteins
• Insulin is used to transport glucose from the blood into
the body cells and tissues
– Use of glucose with insulin prevents fatty acid use
– Used for protein building
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Types of Malnutrition
• 15% to 20% of hospitalized patients are malnourished; reasons:
–
NPO
–
Hypermetabolic
–
Increased protein and energy demands
• Malnutrition leads to immunosuppression and organ dysfunction
• Three types
–
Marasmus
–
Kwashiorkor
–
Protein-calorie malnutrition
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Question
Which of the following would be consistent with
malnutrition?
A. Thin, shiny skin
B. Red, beefy, easily bleeding wounds
C. Hair loss
D. High serum albumin level
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Answer
C. Hair loss
Rationale: Hair cells grow rapidly; patients with
malnutrition will lose their hair when the nurse combs it,
or the nurse may find hair on the bed linen. Thin shiny
skin is consistent with decreased blood flow but isn’t
consistent with malnutrition. Red, beefy, easily bleeding
wounds are those that have re-epithelization. A low
serum albumin level is consistent with malnutrition as
protein is needed to make albumin.
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Enteral Nutrition
• Gut needs to have something in it
• Bacteria translocate into the bloodstream without food
• The best way to receive food is by mouth
• Other ways are needed when eating is contraindicated
• Can give feedings by delivery into the stomach or small
bowel
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Nasogastric, Nasoduodenal, and
Nasojejunal Tubes
NASOGASTRIC
NASODUODENAL
NASOJEJUNAL
Nose to stomach
Nose to duodenum
Nose to jejunum
Short-term use due
to aspiration risk
and nasal erosion
Longer-term use as
tube lies beyond the
pyloric sphincter
Relative ease of
insertion
Harder to insert
Longer-term use as
even less risk for
aspiration than with
nasogastric/nasoduo
denal tubes
Hardest to insert as
must migrate to
jejunum
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Question
A nurse will be inserting a nasojejunal tube to start tube
feedings on a patient with pancreatitis. When the nurse
auscultates the abdomen, bowel sounds are absent.
The nurse decides to hold the tube feeding because this
is a risk for aspiration. Should the nurse institute tube
feedings?
A. Yes
B. No
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Answer
A. Yes
Rationale: Bowel sounds indicate the motility, not
absorptive ability, of the gut. The nurse can institute tube
feedings even if bowel sounds are absent. Also, the small
bowel is less prone to an ileus, so it is OK to feed this
patient.
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Placement and Confirmation of Enteral
Tubes
• Placement
• Confirmation of placement
– Measurement
– Auscultation
– Lubrication
– Fluid aspiration
– Swallowing to help place
– Measuring pH
– Rotate the tube
– Radiological
confirmation
– Use of metoclopramide
(Reglan)
– Weighted tubes
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Question
Which of the following is a proton-pump inhibitor?
A. Famotidine (Pepcid)
B. Sucralfate (Carafate)
C. Pantoprazole (Protonix)
D. Metoclopramide (Reglan)
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Answer
C. Pantoprazole (Protonix)
Rationale: Pantoprazole (Protonix) is the only proton-pump
inhibitor listed. Although all of the other medications are
useful GI medications, they are not PPIs. Famotidine
(Pepcid) is a histamine-2 receptor antagonist, sucralfate
(Carafate) is a slurry that provides a protective covering
in the stomach, and metochlopramide (Reglan) is a GI
motility stimulator useful in decreasing diarrhea with
tube feedings.
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Gastric Tubes
1. Low-profile gastrostomy (LPGD)
2. Jejunostomy tube
3. Percutaneous endoscopic gastrostomy (PEG)
4. Percutaneous endoscopic gastrostomy with jejunal
extender (PEG/J)
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Tube Sites
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Care of Gastric Tubes
• Securing tubes
• Document the external length
– Assess skin for breakdown
• Prevent maceration
• Good hygiene – soap and water cleansing
• “Buried bumper syndrome”
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Types of Feedings
• All contain carbohydrates, fats, and proteins
• Types
– Polymeric solutions
– Peptide
– Modular
– Immunonutrition-containing diets
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Frequency of Feedings
BOLUS
CONTINUOUS
CYCLIC
By syringe
By feeding pump
During the night (8 to 12 hrs)
5 or 6 times/day
Continuous
Requires a feeding pump
ADVANTAGE
ADVANTAGE
ADVANTAGE
More like eating
Allows more absorption time
Shorter time
Increased patient mobility
Less risk of stress ulcers
Fewer metabolic problems
High volume and density at
night; greater patient
mobility
DISADVANTAGE
DISADVANTAGE
DISADVANTAGE
Aspiration a problem
“Dumping syndrome”
Increased residuals
Increased residuals
Mechanical device with power
source
Cramping, nausea, bloating,
and diarrhea
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Complications of Feedings
• GASTROINTESTINAL
– High residuals
– Nausea, vomiting,
bloating
– Diarrhea (most
common)
• METABOLIC
– Preventing acute renal
failure
– Preventing
overhydration
– Hyperglycemia
– Constipation
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Complications (cont.)
• INFECTIONS
– Aspiration, which is potentially fatal
– Occurs with endotracheal intubation about 50% to
75%
– Treatments
• Keep HOB elevated
• Discontinue 30 minutes before lying flat
• Aspirate for residuals and trend
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Question
In determining whether a patient has aspirated, blue dye
instillations or additions are no longer acceptable
practice and can cause more harm to the patient.
A. True
B. False
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Answer
A. True
Rationale: Using blue dye is no longer an acceptable
practice in determining aspiration. Blue dye can cause
toxicity, invasion of bacteria, and diarrhea.
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Parenteral Nutrition
• Delivery of food into the vein instead of the stomach
• Only short term until food can be instituted, or can be
done in combination with enteral/oral nutrition
– Will not stop translocation of bacteria
• Types
– PPN (peripheral parenteral nutrition)
– TPN (total parenteral nutrition; hyperalimentation)
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Sites for PPN/TPN Delivery
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Differences Between TPN and PPN
• PPN
• TPN
– Large peripheral vein
(basalic vein)
– Lower osmolality
(<800mOsm/L)
– Short term for
prevention of
malnutrition
– Central venous access
(superior vena cava or
internal jugular)
– Higher osmolality
– Longer term
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Constituents of Parenteral Therapy
• Carbohydrates
• Lipids
• Amino acids
• Micronutrients
• Medications
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Complications of Parenteral Nutrition
• GI
• MECHANICAL
– Hepatic dysfunction
– Cholestasis
– Cholelithiasis
– Gastric atrophy
– Usually due to central
line insertion
– Catheter occlusion
– Venous thrombosis
– Venous air embolism
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Complications of Parenteral Nutrition
(cont.)
• METABOLIC
• INFECTIOUS
– Hypokalemia
– Hyperglycemia
• Sliding scale coverage
– Hypoglycemia
• Substitution of D10W
(temporary)
– Refeeding syndrome
– High glucose is excellent
environment for
bacterial growth
– Change bag and tubing
per protocols
– Check insertion site and
change dressings
– Antibiotics and catheter
tip culture if infection is
suspected
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