Why is enteral feeding preferred over parenteral?
it improves utilization of nutrients
generally safer
maintains structure and function of the gut
less expensive
Why would you give enteral feedings?
impaired swallowing/gag
nutritional deficit due to reduced food ingestion or hypermetabolic state even when the pt is able to eat
inability to eat related to surgery, injury or decreased LOC
When can a feeding tube be placed orally?
trauma to the nose
endotracheal tube is already in place in the mouth
Why are weighted tubes used?
They can stay in place longer
Why do you need to assess for the gag reflex before inserting an NG tube?
no gag reflex puts them at a greater risk of aspiration
What is a prokinetic agent and when do you give it?
An agent that you give before putting in the tube that helps it advance to the gut faster
Can you insert an NG tube into a pt with a decreased LOC?
yes, but the risk for aspiration is greater
How do you position an alert pt for a feeding tube?
at 30 degrees or in high fowlers
How do you position a comatose pt for feeding tube insertion?
semi-fowlers with head propped forward using a pillow
How do you position a patient who must stay laying down when you insert a feeding tube?
reverse Trendelenburg
After you have assessed and positioned your patient, what is the next step to inserting the NG tube?
measure the length from the tip of the nose to the earlobe and then to the xyphoid process and then mark it
How would you measure the length for an NI tube?
the same as for an NG but add on another 8-12 inches
After you measure your tube, what do you do?
draw up 10 mL of water and make sure the guide wire is securely positioned against the weighted tip and that the luer-locks are tight
After you draw up the water and check your guide wire, what do you do?
Dip tube with surface lube into room temp water or apply water-soluble lube
Why can't you put the tip into cold water?
it will become stiff and inflexible
What should you do after lubricating the end of the tube?
Give the patient water and instruct him to raise his hand if it becomes too uncomfortable
After you give the patient water, how do you proceed?
gently insert tube through the nostril and to the back of the throat. Then have the pt lean forward as it passes the nasopharynx
Why do you have the pt lean forward?
to reduce the risk of going into the lungs
When should you stop inserting? Why?
When the tip is at the carina so you can listen for air exchange from the distal portion of the tube
What should you do if you hear air exchange?
remove the tube and start over
What should you do if you encounter resistance or the pt coughs, chokes or becomes cyanotic while you're inserting the tube?
stop advancing, pull back and start over
Once the tube is inserted, what should you do?
Check the back of the throat to see if it's coiled, kinked or entering the trachea
How long should you keep the guide wire in place?
until the correct position is ensured by an x-ray
What should you do if the guide wire is partially removed? Why?
DO NOT try to reinsert it. It can cause a perforation in the tube and injure the pt
What is a bedside way to test for correct insertion?
put in 30mL of air, pull out the contents and measure the pH
What will gastric contents measure at?
<4
What will intestinal contents measure at?
>6
What will pleural contents measure at?
>6
What should you do if the tube goes into the respiratory tract?
remove the tube and report the incident to the dr. obtain order for re-insertion
What should you do if stomach contents aspirate into the respiratory tract in an alert patient and the patient coughs, has dyspnea, cyanosis or decreases in SaO2 during the procedure?
position the client on his side to protect the airway
suction the client nasotracheally or orotracheally to try to remove aspirated substance
report the event immediately to the dr
What should you do if the stomach contents aspirate into the respiratory tract in small volumes and you hear crackles or wheezes or the pt has dyspnea or a fever?
report change in pt condition to the dr
if there has not been a recent chest xray, suggest one be ordered
prepare for possible initiation of antibiotics
What should you do if the tube becomes clogged?
irrigate the tube
What should you do if the nasal mucosa becomes inflamed?
retape the tube in a different position to relieve pressure
if the tube has been in the same site for an extended period, consider reinsertion of the tube in the opposite nares with a dr's order
When giving a continuous enteral infusion, how do you prepare the feeding?
give it at room temp and shake
How often should you confirm proper tube placement?
every 8-12 hours and before meds are administered
How do you check proper tube placement?
draw up 30mL of air, inject and aspirate gastric contents
How much residual makes up delayed emptying?
>100
What pH are you looking for when you're looking for proper placement?
1-4
What should you do with the aspirants if you have less than 100mL?
return them
Why do we return stomach contents?
they contain electrolytes that are necessary to maintain balances
What should you do if there is over 100mL of aspirate?
notify the dr and request an order to return them or not
After testing for residual, how do you start the feeding?
pinch the end of the tube
remove the plunger from the syringe and attach to the tube
Fill with measured amount of the formula and release tube
How high should you hold the syringe?
about 18 inches above the insertion site
How do you administer a feeding bag?
prime the tubing, attach gavage tubing to the end
set rate
label with feeding type, strength, amount, date, time, initials
What is the maximum hang time in an open system?
8h
What is the maximum hang time in a closed system?
24h if it remains closed
What should you do when feedings are not being administered?
cap or clamp the proximal end of the feeding tube. Rinse bag and tubing with warm water whenever feedings are interrupted.
What formula can you start at full strength for an intermittent feeding?
isotonic
How do you increase the rate of tube feedings for intermittent feedings?
begin with no more than 150-250mL at one time. Increase by 50mL per feeding per day to achieve needed volume and calories in six to eight feedings
What's one way you can make sure someone gets all their nutritional needs if they're building up a tolerance?
give concentrated formulas at full strength
How are hypertonic formulas started for a continuous feeding?
at full strength but at a slower rate
How are isotonic formulas started for a continuous feeding?
full strength
How should you advance a continuous feeding?
10-20mL/hr per day to target rate if tolerated
How do you assess tolerance of an enteral feeding?
absence of nausea and diarrhea and low gastric residual
What assessments do you have to do when giving enteral feedings?
residual
accucheck
I&O
weight
labs
respiratory
bowel sounds
What should you use to unclog the tube? What should you avoid?
use water. Don't use cranberry juice.
What should you do if the pt develops diarrhea 3x or more in 24h while doing tube feedings?
tell dr, confer w dietician to determine need to modify type of formula, concentration or rate of infusion
consider other causes
determine if client is receiving antibiotics or meds that can induce diarrhea
What should you do if the pt develops nausea and vomiting while on gastric feedings?
may indicate gastric ileus. Withhold tube feeding and tell dr
Be sure tubing is patent, aspirate for residual
What should you do if the aspirated fluid has a foul odor or unusual appearance?
notify dr and document the findings. Do not return aspirated material of unusual odor or appearance without consulting the dr.
What does it mean when you aspirate red or brown coloring like coffee grinds?
tell the dr immediately if it's not related to medications recently administered
What should you do if pt develops severe respiratory distress while aspirating tube?
notify dr
stop any feedings
obtain chest x-ray as ordered
What does it mean if the abdomen becomes distended when you aspirate? What should you do?
feeding tube may be in the esophagus. Notify dr and stop feedings.
How do you start a feeding tube irrigation?
verify tube placement w aspiration
draw up 30mL NS or water
kink tube while disconnecting it from bag. Place end of bag tubing on towel
insert tip into tube and release kink to instill irrigation solution
What should you do if you're not able to instill fluid? Why?
reposition client on left side and try again bc tube may be against stomach wall
What should you do if moving the pt doesn't improve tube function?
notify dr. tube may need to be removed and a new one placed.
What should you do once the water has been instilled?
remove the syringe, reinstitute tube feeding or give meds as ordered
When should you irrigate?
before meds, between different meds and after final meds (before feedings are reinstituted)
How do you remove a feeding tube?
Stand on the side with your dominant hand
have pt take deep breaths and exhale slowly
remove tape
withdraw slightly and smoothly into a towel
provide face and mouth care
What are some of the circumstances that affect your metabolism?
gender
increased/decreased BMR
Which sex has a higher metabolism?
men
What can increase your BMR?
hyperactive thyroid
growth
infection
stress
temperatures
What can decrease your BMR?
starvation/prolonged fasting
sleep
aging
What is a positive energy balance?
intake is greater than output
weight gain
What is a negative energy balance?
intake is less than output
weight loss
Where do we intake N2?
protein
Where do we excrete N2?
kidneys
urine
stool
sweat
What does your BMI use for ideal body weight?
height and weight
How many calories are in 1lb of fat?
3500
What is a desirable BMI?
18.5-24.9 kg/m2
At what waist size do women have increased health risks?
35inches
At what waist side do men have increased health risks?
40in
Where is the most dangerous place to carry weight?
in the middle
What can a pear shaped body lead to? What is the cutoff point for increased risk in women?
varicose veins and orthopedic problems. 0.8 wait to hip ratio
What can an apple shaped body lead to? What is the cutoff point for men?
increased risk for type 2 diabetes, heart disease, HTN. 0.95 hip to waist
What does soluble fiber do?
dissolves in water to slow down digestion and make you feel full longer
What does insoluble fiber do?
does not dissolve in water and helps with motility and preventing constipation
How many essential amino acids are there?
9
What kind of pt needs to consume more protein?
post op