Transcript CHAPTER 6 PATIENT CARE SKILLS

CHAPTER 5
PATIENT CARE SKILLS
Assisting with Enteral Nutrition
Assisting with Enteral Nutrition
Objectives
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Define the key terms in this chapter
Describe the routes for enteral nutrition
Explain the purpose of enteral nutrition
Describe how to handle formula for enteral nutrition
Explain the difference between scheduled and continuous feedings
Explain how to prevent aspiration and regurgitation
Identify the signs and symptoms of aspiration
Describe the comfort measure that relate to enteral nutrition
Explain the safety precautions involved in giving tube feedings
Identify the reasons for removing a nasogastric tube
Perform the procedures described in this chapter: giving a tube feeding,
removing a nasogastric tube.
Enteral nutrition=giving nutrients through the
GI tract.
 Feeding tube inserted into the stomach or
small intestine.
 used when food can't pass normally from the
mouth into the esophagus and into the
stomach
Conditions that are common
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cancer of the head neck, or esophagus
trauma to face, mouth, head or neck.
surgery to face, mouth, head, or neck.
coma
dementia
Types of feeding tubes
Temporary
A. nasogastric tube (NG)
 inserted through the nose into the stomach.
 performed by a nurse or doctor
B. nasointestinal tube (NI)
 inserted through the nose into the duodenum or
juejunum of the small intestine
 doctor or RN performs procedure
Types of tube feedings
Permanent
A. gastrostomy
• opening into the stomach created surgically
B. jejunostomy
• inserted into the middle part of the small intestine
• created surgically
C. percutaneous endoscopic gastrostomy (PEG ) tube
• inserted with an endoscope through the mouth and esophagus
into the stomach.
• incision is made through the skin and into the stomach, tube is
inserted through the incision.
Methods of Administering
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Syringe
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Feeding bag
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Uses a 60 ml syringe
Flow rate is controlled by gravity
Formula is poured into a bag hung from IV pole
Flow rate is adjusted by the height of the bag on the pole
Feeding pump
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Formula poured into a bag and tubing is threaded through a
machine
Rate is controlled by the pump
Feedings
Scheduled
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May be Scheduled or continuous feedings
ordered by the doctor which way to be given
Feedings
Bolus intermittent feeding
receives a large amount of formula over
a relatively short period of time.
Feedings
Continuous
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require feeding pumps
can be nasointestinal or jejunostomy tube feedings
formula is to be kept at room temperature: cold can
cause cramping
formula is added every 3 to 4 hours
never add new formula to formula in the bag d/t
contaminated
never hang more than 4 hours to prevent the
growth of microorganisms
Feedings
Cyclic feeding
receives small amounts of formula
constantly for 8 to 12 hours; then the
person is disconnected from the feeding
pump.
Feedings
scheduled
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usually given four times a day
given with a syringe or feeding bag
approximately 400 ml over 20 minutes
amount and rate like a regular meal.
Children and Elderly
Children
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NG, G tube and PEG tube feedings more common
usually scheduled not continuous
position for feeding would be in your lap to allow for comfort of
the child
elevate the head and chest
position on right side or Fowler’s position for 1 hour (usually
directed by RN) if able
amount of formula and position for feeding directed by RN
infants get pacifiers to suck on during the feeding to allow
normal sucking reflex, comfort and reduce crying
note cramping, vomiting, discomfort
Children and Elderly
Elderly
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increased risk of regurgitation d/t slowing of
digestion and stomach emptying
less formula and longer feeding time than
other adults
May be unable to stay on side or back for
longer than 1 hour
Formulas
Many different types but common factors in each
 Most contain protein, carbohydrates, fat,
vitamins, and minerals.
 Commercially prepared or prepared by dietary
department in house
 Can provide an environment for the growth of
microorganisms.
 Must not contaminate when handling
Preventing contamination of formulas
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Wear gloves when preparing or handling formula
replace soiled gloves as necessary
Do not use dented or damaged cans.
Check the expiration date on commercial formulas.
Check the date on formulas prepared by the dietary department and
Discard if >24 hours
Wash cans or bottles before opening them.
Label cans or bottles with the time and date opened.
Refrigerate open cans or prepared formula
Clear the tube before and after the feeding using 30-50 cc of water
or other fluid per facility policy
Counted as part of the pts intake
Complications
Aspiration
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a major complication of NG and NI tubes
Defined as breathing of fluid or an object into the lungs
placement can cause the tube to slip into the respiratory
tract.
must be determined by an x-ray to assure that tube is in the
stomach or SI
may move out of place with coughing, sneezing, vomiting,
suctioning, and poor positioning.
***RN checks for placement before every scheduled tube
feeding, continuous every 4 to 8 hours by aspirating GI
secretions
General care measures
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Provide oral care
General care measures
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Monitor bowel movements
General care measures
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Prevent complications
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Aspiration
HAI
Dehydration
Dumping syndrome
Aspiration
-signs and symptoms
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nausea
discomfort during the feeding
vomiting
diarrhea
distended abdomen
coughing
complaint of indigestion or heart burn
redness, swelling, drainage, odor, or pain at site of ostomy
elevated temp
respiratory distress
increased pulse
complaints of flatulence
Complications
Regurgitation
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backward flow of food from the stomach into the
mouth
can occur with NG, G, PEG tubes
less often with NI, J tube
common causes
1. delayed stomach emptying
2. overfeeding
prevention
-sitting or semi-Fowler’s position for feeding and remain for 1
hour after.
*******never left side lying position*******
Comfort measures
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usually NPO, causes dryness of mouth, lips, sore
throat
may be allowed hard candy or gum, check care
plan
frequent oral hygiene
lubricant for the lips
mouth rinses
Nose and nostrils are cleaned q 4 to 8 hours
secure NG tube with tape to nose and gown to
relieve pressure on nose
Giving a tube feeding
You may assist the RN and then complete on own as AP and PCT
guidelines to follow before giving a tube feeding
 must be allowed by the state
 be in job description
 by educated and trained to perform
 know how to use the equipment at the facility
 review the procedure with the RN
 RN available to answer questions
 RN checks tube placement
***patient may have IV infusions, drainage tubes, and
breathing tube as well as GI tube. MUST KNOW THE
DIFFERENCE****
Report to the Nurse Immediately
Coughing or wheezing
Diarrhea or constipation
Difficulty breathing
Fever
Low reading on pulse
oximeter
Abdominal pain or bloating
Cyanosis
Dry mucus membranes
Nausea or vomiting
Decreased or very
concentrated urine
Total Parenteral Nutrition
How TPN Differs From Enteral Nutrition
TPN bypasses the digestive tract and
delivers the nourishment directly into the
bloodstream and is not digested.
TPN is administered through a central line
into one of the two large veins that empty
directly into the heart.
TPN is a solution that contains nutrients in their
smallest form.
Patients who receive TPN are very ill, injured, or
may be recovering from surgery, especially
gastrointestinal, and may not be able to tolerate
food in the digestive tract.
Removing a nasogastric tube
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removed when the person can eat and swallow.
must be free of nausea and vomiting
MD orders the removal of the tube
check job description and state regulations
Use Standard Precautions and The Bloodborne
Pathogen Standard guidelines
report observations
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any bleeding
pt tolerance of procedure
pain or discomfort during or after procedure
Bellwork
1. List two ways that a Patient Care Technician can prevent
contamination of enteral nutrition formulas (1 pts)
2. Identify the following tubes by their placement and insertion site
(2 pts)
nasogastric tube
gastrostomy tube
jejunostomy tube
PEG tube
3. Define aspiration and give a common cause for its occurrence
(1 pts)
4. Explain the difference between continuous feeding and
scheduled feeding
(1 pts)
Skill #1
- Giving
a tube
feeding
-see procedure in
the chapter
Skill #2
-Remove a
nasogastric
tube
-see procedure in
the chapter
SKIN PUNCTURES
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= penetration of the capillary bed in the
dermis of the skin with a lancet or other
sharp device to collect a blood specimen
=especially important in pediatrics
=fingers in adults and children older than 2
=heels of infants
Taking a blood glucose
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Skill practice
Equipment
 Lancet
 microcollection tube/container
 microhematocrit tube
Site selection criteria-skin puncture
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warm, pink, or normal color
free of scars, cuts, bruises, or rashes
no cyanosis
no edema
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Infants
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heel recommended site for infants less than 1
year
precautions: DO NOT PUNCTURE
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deeper than 2.o mm
through previous puncture sites
the area between the imaginary boundaries
the posterior curvature of the heel
in the arch causing injury to nerve, tendons, and
cartilage
areas of the foot other than the heel
 older children and adults
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palmar surface on the distal segment of finger
usually nondominant hand
fleshy central portion, slightly to side and tip
perpendicular to whorls(grooves in the fingerprint)
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DO NOT PUNCTURE:
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Side or tip of the finger
Parallel to grooves of the fingerprint
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The index finger
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causes blood to run down the finger rather than form a
round drop
more callused and harder to poke
used more often and cause more pain
Fifth or little finger
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thinnest tissue
– Fingers of infants and very young children
Nursing Assistant’s Role
Check that the dressing over
the central line insertion site is
clean and dry
Notify the nurse if the
dressing becomes wet, soiled,
or loose
Monitor the patient’s blood
glucose levels
Monitoring Glucose Levels
The TPN solution is very concentrated and
contains a great deal of glucose
It is delivered directly into the bloodstream,
causing the body to have difficulty monitoring
and regulating the blood glucose level
Glucose levels should be monitored every 6
hours
Patients taken off TPN should continue to
have their glucose levels checked for
hypoglycemia
PERFORM A SKIN PUNCTURE
Key Terms
Genitourinary Skills
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Ostomy
loop stoma
double barrel stoma
end stoma
enterostomal therapy
ileostomy
effluent
colostomy
irrigation
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stenosis
perforation
prolapse
diverticulitis
flatus
herniation
necrotic
peristomal
Ostomy Care
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Ostomy= a surgically created opening that
serves as an exit site for fecal matter.
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Colostomy=an opening created anywhere
along the large intestine or colon
Ileostomy=an opening into the ileum or
terminal portion of the small intestine
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Reasons for using a stoma
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Genetic defect
Inadequate blood flow
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Removal of necrotic section
Traumatic adnominal injury
Disease process
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Cancer
Diverticulitis
Polyposis
Crohn’s disease
Ischemic bowel
Ulcerative colitis
TYPES OF STOMAS
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Loop stoma
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Loop of intestine is brought to the abdominal
surface
Usually temporary, closed in 2-3 months
Bowel function returns to normal
TYPES OF STOMAS
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Double barrel stoma
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A portion of the bowel is removed and both ends
are brought to the surface to form two stomas
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Proximal=functioning part
Distal=non-functioning part
May be permanent or rejoined when healed
TYPES OF STOMAS
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End stoma
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Created when disease or pathology is present
Affected portion and all parts below it are
removed to prevent further spread
Stoma will be proximal to affected area
Permanent or temporary
Anatomy review
Small intestine
-primary functions
1.digestion
2. some absorption
-26 ft. long and one inch in diameter
-parts
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duodenum
jejunum
ileum
-effluent (output or drainage from a stoma) is semiliquid and caustic to the skin.
Anatomy review
Large intestine
-two primary functions
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absorption of water
transportation and storage of fecal matter
-6 to 8 ft long and 2 ½ inches in diameter
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ascending colon
transverse colon
descending colon
sigmoid colon
-effluent ranges from liquid to semi-formed to formed
depending on the location
-not as corrosive as to the skin
Choosing a pouch system
DETERMINING FACTORS:
1. Type of effluent
– liquid of fairly constant would take a drainable
pouch
– formed would take a security pouch with a closed
end
2. Presence of disabilities
- a patient with limited manual dexterity would use a
one-piece system
- a two-piece system for those who are mobile and
able to reach the ostomy site without difficulty
Choosing a pouch system (con’t)
3.Personal preference
-pt must feel comfortable and capable
4. Physiology
-size and shape of the stoma
-size and contour of the abdomen
-peristomal skin condition
-physical activities/ manual dexterity
-opening of the skin barrier for the stoma will
continue for six to eight weeks
Changing a pouch
*See procedure sheet*
Equipment needed
written instructions for the patient
clean towel
washcloth
soap and water
measuring guide
flange
pouch
pouch clamp
pen
scissors
protective skin barrier paste
disposable bag
-enterostomal therapy occurs after the stoma is
placed during surgery (therapy to help the patient
with care of the stoma and peristomal area)
-postoperatively the enterostomal nurse (ET nurse) is responsible
for the preparation and application of the post-op pouch and the
following responsibilities:
– remeasure the stoma each time the pouch is changed
– Check the pouch for leakage
– Any complaints of itching or burning should be assumed as
leakage
– Empty the pouch when it is one third full of stool or flatus
(air in the intestine that causes gas) high output post-op,
then 600 to 1000cc for 2 months
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Monitor the stoma
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-normal=red, moist, and shiny, with skin intact
Document observations in the chart
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-amount of effluent
-appearance of stoma
-appearance of the peristomal area
SKILL #3
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Perform change a pouch
BELLWORK
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Explain the difference between a colostomy and an
ileostomy’ (1 pt)
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How is the type of pouch system determined. (2 pts)
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Define effluent. (1 pt)
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Determine the difference in the effluent from a
colostomy and an ileostomy (1 pt)
Patient Education
-teach basic anatomy and physiology, self care
techniques
*how to empty the pouch
*how to measure the stoma
*how to cut the opening in the skin barrier
*how to apply the pouch and clamp
-teach from simple to complex.
-irrigation (cleansing the colon by flushing with water)
may be taught but will depend on the patient and
bowel function
-most require immediate attention
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skin breakdown
blockage
obstruction
continuous stomal bleeding
prolapse (a falling or dropping down the intestine)
herniation (when the intestine protrudes into the abdomen)
stenosis (constriction or narrowing of the opening)
perforation (a hole made through a part)
dehydration
Diet
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a dietician is needed for educating the
patient post-op.
foods given post-op depend on the ostomy
site
advise to avoid foods that cause excessive
odor, flatus, constipation, or diarrhea
new foods introduced one at a time, until
effects are known
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celery
Chinese food
nuts
coconut
wild rice
popcorn
whole grains
coleslaw
seeds/kernels
raw veggies
raw fruits
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fish
eggs
asparagus
onions
garlic
beans
peas
cabbage
turnips
Gas
Forming Foods
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cabbage
beans
Mexican
Dairy
Mushrooms
Beer
Carbonated drinks
Pickles
Eggs
Onion
Broccoli
Corn
Yeast
Spinach
green beans
broccoli
spinach
raw fruit
fried foods
highly seasoned foods
Foods that Change color of stool
beets
tomatoes
strawberries
spaghetti sauce
Control diarrhea
bananas
applesauce
boiled rice
boiled milk
tapioca
yogurt
buttermilk
peanut butter
Psychological complications
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depression
withdraw from activities
decreased self-esteem
change of self image
QUESTIONS ????????????