What is parenteral nutrition?
Administration of nutrients by route other than GI tract (i.e., bloodstream)
Storage and labelling of parenteral nutrition includes?
Must be refrigerated until 30 minutes before use; made daily, only good for 24 hours
Must be labeled with nutrient content, all additives, time mixed, and date and time of expiration
What are common indicators for PN?
- Chronic severe diarrhea and vomiting
- Complicated surgery or trauma
- GI obstruction
- GI tract anomalies and fistulae
- Intractable diarrhea
- Severe anorexia nervosa
- Severe malabsorption
- Short bowel syndrome - Occurs when a patient has a problematic portion of bowel cut out, and problems reoccur a few years later. Pt has more cut out, and it again occurs later on. Repeating.
What are common metabolic problems associated with PN?
- Altered renal function
- Essential fatty acid deficiency
- Hyperglycemia, hypoglycemia - Check blood glucose via finger blood stick q4-6hrs
- Hyperlipidemia
- Liver dysfunction
- Refeeding syndrome - Electrolyte imbalances, Fluid imbalances which lead to edema
What is nursing management of PN?
Vital signs q4-8hrs
Daily weights
Blood glucose
- Sliding scale
- Check every 4-6 hrs
Electrolytes
BUN
CBC
Liver enzymes
Dressing change
- Per policy
- Site observation is key!!
Refeeding syndrome
Infusion pump must be used
- Need to periodically check volume infused
- Check more often than regular IV
Watch for infection and sepsis
What are S/S of infection and sepsis with PN? and interventions if suspected?
Local manifestations - Erythema, Tenderness, Exudate at catheter insertion site
Systemic - Fever, chills, Nausea/vomiting, Malaise
If suspected:
- Blood and catheter cultures if infection suspected
- X-ray: To check changes in pulmonary status
- After PN therapy, daily dressing changes to infusion site until it fully heals (After catheter is removed)
BMI categories
< 18.5 Underweight 18.5-24.9 Normal weight 25.0-29.9 Overweight >29.9 Obese >40 Extreme Obesity
What are ways to assess obesity?
BMI
Waist circumference
Waist to hip ratio
body shape
Waist circumference measurements:
increased health risk if >40 in men and > 35 in women
Larger waist = increased heart disease
Waist to hip ratio
> 0.8 greater risk for health complications
Apple body shape is at risk for:
Heart disease
DM
Hypertension
Pear body shape is at risk for:
osteoporosis
varicose veins
All opportunities for patient education on obesity should stress (2), and should include (6).
healthy eating and exercise
- Meal planning
- Adequate fruits and vegetables to prevent constipation, meets vitamin A and C requirements
- Lean meat, fish, and eggs for protein and B-complex vitamins (B complex vitamins can be insufficient if diet has not carbs)
- Exercise
- Behavior modification
- Support groups
Bariatric surgery is used to treat ___.
extreme obesity. It is currently the only treatment found to have a successful and lasting impact for sustained weight loss
Criteria guidelines include:
- BMI ≥40 kg/m2 OR
- 35 with one or more significant co-morbidities (such as hypertension, DMII, HF, sleep apnea)
Not always covered by insurance; Screened for psychologic issues associated with poor outcomes (depression, binge eating disorder, drug/alcohol abuse)
The three broad categories of bariatric surgeries are:
restrictive (reduces size of stomach or amount allowed to enter the stomach),
malabsorptive (small intestine is shortened),
and a combo
Bariatric surgeries include:
Restrictive:
- Gastric banding
- Sleeve Gastrectomy
- Plication
- Intragastric Balloon
Combo:
5. Roux-en-Y Gastric Bypass (RYGB)
Gastric banding
restrictive surgery that limits the size of the stomach with an inflatable band, adjustable
- Port is subcutaneous that can be inflated or deflated by fluid injection in provider’s office
- Creates sense of fullness
- Delays in stomach emptying
- Can be modified or reversed later
Sleeve Gastrectomy
restrictive surgery in which 75% of stomach is removed, leaving a sleeve-shaped stomach
- Stomach function preserved
- Eliminates hormones made in the stomach that stimulates hunger
- Currently requires a surgical incision, research ongoing on laparoscopic approach
- Leakage related to stapling or sutures possible
- NOT reversible
Plication
restrictive surgery in which a 2. sleeve is created by suturing rather than removing stomach
- Minimally invasive surgery (compared to sleeve gastrectomy)
- Involves folding stomach wall inward, reducing the stomach volume
- Reversible
- Requires hospital stay
- Nausea common after procedure
- Blockage may occur from swelling or fold too tight
Intragastric Ballon
A restrictive procedure in which a balloon occupies space in the stomach
- Natural anatomy of the stomach is not altered
- Patients feel more full, appetite decreased
- Less invasive, placed using - - Balloon filled with saline, varying amounts can be used (400-700 mL) –OR- nitrogen gas (newer)
- Can only be left in for 6 months
Roux-en-Y Gastric Bypass
a combination surgery in which a stomach pouch is created, connected to jejunum, rest of stomach and first part of small intestine bypassed
- Food bypasses 90% of the stomach, duodenum, and a small segment of jejunum
- **Most common bariatric procedure **
- Excellent patient tolerance
- Has low complication rates
Possible complications of Roux-en-Y Gastric Bypass surgery:
- DUMPING SYNDROME
- also called rapid gastric emptying
- causing abdominal cramps and nausea and diarrhea, due to insulin surge, symptoms of hypoglycemia occur 2-3 hours later
- Avoidance of sugary foods, small frequent meals and dietician referral can all help - LEAK AT ANASTOMOSIS SITE - this is a concern for every stomach surgery procedure!
- ANEMIA
Preoperative Care for a Bariatric surgery:
Patients will likely have comorbidities, so team approach
Nurse myst prepare the room!
1. Have room ready for patient before arrival
- Larger blood pressure cuff
- Larger gown
- Patient transfer equipment
- Wheelchair with removable arms
(Note: Don’t make a large pt uncomfortable by making them feel like you have to provide special accommodations “Oh, I need a larger bp cuff, let me get it!” :O )
- Wound infection – skin prep important
- Breathing - Coughing, Deep breathing, Turning - These are super important in obese patients to avoid pulmonary complications*
- Venous access -> Have an extra long catheter
- Mechanical ventilation
Postoperative care for Bariatric Surgery:
- Close observation for complications
- Transfer with specially trained personnel
- Stabilize airway -
* *Elevate HOB to 35-40 degrees** - Adipose tissue problems
- Anesthetic agents stored in adipose tissue, may be slower to wake and/or re-sedation possible
- Excess adipose tissue compresses chest and abdomen which Causes CO2 retention - Manage pain
- Diligent turning and ambulating
- Hypoxemia, pulmonary hypertension, polycythemia
- Risk for deep venous thrombosis (DVT)
- TED hose and PCD devices should be put on at night or when pt is NOT moving around - Infection, dehiscence, delayed healing
- Nutrition is KEY!! - Keep skin folds clean and dry to prevent bacterial or fungal infections
- Attentive to placement of NG tube
- Careful transition to new diet
