Nutrition and GI skills care Flashcards
(56 cards)
1
Q
Assessment of nutrition of GI
A
Nutritional screening
- 25% of adults in hospitals are malnourished after being there for a couple of days
- Higher risk for pressure ulcers, dehydration, constipation, etc.
Nutritional assessment
- Assessments are usually done by dietitians
Patient preferences
- Important as a RN to know
- Ask what they prefer
Lab values
- Important nutritional assessment
- example: Albumum
Physical assessment
2
Q
Phases of swallowing
A
1) Oral
- Food taken into mouth and stimulated different sense
- Creates a ball called a bolus
2) Pharyngeal
- Bolus arrises in throat and triggers swallowing reflex
- Glottic closes and allows passage into esophagus instead on airway
3) Esophageal
- Passage of bolus from esophagus to stomach due to sphincter
3
Q
Dysphagia
A
Impairment in any stage of the swallowing process
often neurological disease such as stroke, etc
4
Q
Aspiration
A
- Fluids or bolus go down wring tube into lungs instead of stomach
5
Q
Silent aspiration
A
- Don’t show signs/symptoms of aspiration while it’s occurring
6
Q
Possible symptoms of dysphagia and aspiration
A
- Coughing during meals
- Hoarse voice following meals
- Drooling
- Upper respiratory infection
- Pneumonia
7
Q
Symptoms of aspiration pneumonia
A
- Fever
- Hear crackles when listening (coarse or fine) and hear when patients have a lower lobe pneumonia
- Dullness when percussing lungs; consolidation in lungs
- General malaise, feeling really horrible
8
Q
Safety during feedings
A
- Positioning – upright 90 degrees
- Flex neck for ‘chin-down’
- Avoid rushing
- Alternate solid & liquid boluses
- Place food in stronger side of mouth
- Mechanically-altered diets -determine food viscosity best tolerated
- Minimize use of sedatives and hypnotics
- Minimize distractions
- Adaptive equipment if client is able to feed self
- Oral hygiene
9
Q
Safety after feedings
A
- Positioning – patient should remain upright for 30 minutes
- Check for pocketing of food
- Note and document intake
- Note any foods that are preferred
- Note any foods the patient has difficulty with
- Oral hygiene
10
Q
Therapeutic diets and mechanically altered diets
A
- Regular
- Mechanically altered such as soft diet
- Pureed diet
- Full liquid, clear liquid
- Low sodium
- No added salt
- High protein
- Therapeutic diets aren’t really realistic once someone has left the hospital
11
Q
Thickened fluids diet
A
Thin - no alteration
Nectar like - slightly thicker than water, like unset gelatin
Honey like - a liquid with the consistency of honey
Pudding like or spoon thick - a liquid with the consistency of pudding
12
Q
Enteral nutrition
A
- Nutrients provided through the GI tract distal to the oral cavity via a tube, catheter, or stoma
- Also called gavage or enteral tube feeding
13
Q
Indications for enteral nutrition
A
- Client unable to ingest food but can still digest and absorb nutrients
- Can be for a variety of reasons
14
Q
Types of entral access tubes
A
1) Nasal or oral insertion
- Nasogastric tube (Levin or Salem sump)
- Nasogastric or nasointestinal tube – small bore feeding tube (Keofeed/Dobbhoff)
- Orogastric or orointestinal - small bore feeding tube (Keofeed/Dobbhoff)
2) Surgical insertion
- Gastrostomy (G-tube)
- Jejunostomy (J-tube)
3) Endoscopic insertion
- PEG (percutaneous endoscopic gastrostomy)
- PEJ (percutaneous endoscopic jejunostomy)
15
Q
Insertion of a nasogastric (NG) tube
A
- Measure from tip of nose to earlobe and to the tip of the xyphiod process
- Want end to reach the stomach
- If not far enough risk of aspirating and going into trachea
- Not a sterile procedure; but want to wear gloves and mindful that can elicit gag reflex and potential for vomiting
- Sit them up; encourage them to drink water if possible during insertion
16
Q
Small-bore enteral feeding tube
A
- Often starts with thicker tube; if need feeding over period of time more to smaller one for more comfort
- Don’t want them to get blocked
17
Q
Insertion of enteral tube: surgical or endoscopic insertion (PEG/PEJ)
A
- Light swallowed to guide insertion into the abdominal wall
- Comes in difference sizes in the French; starts small and advance in sizes going up
- Balloon on end to prevent falling out
18
Q
Verifying tube placement
A
- Radiographic assessment - gold standard - before initiating feeding or medication administration
- pH testing of gastric aspirate
- Capnography- detecting expired CO2 by attaching device to end of tube
- Note respiratory distress – may not be reliable
- Aspiration of stomach contents; no longer recommended
- Auscultation; no longer recommended
- Has to be performed every time a tube is inserted, and before the first feed
19
Q
Checking tube placement: pH testing
A
- Draw contents up with syringe through tube
- pH lower than 5 suggestsgastric placement
- pH higher than 5 may indicate intestinal or respiratory placement
20
Q
Care of the patient with an NG tube
A
- We never lay the patient down flat; try hard to avoid
- Having them sit up at least 30 degree is important; some patients that’s not enough and has to be higher
- Leave them up for 30 minutes minimum before changing positions (post-feeding)
- Tape can be placed to anchor tube; ensure it’s clean dry and intact
- Skin around nares is dry, clean, intact
- If attached to face; well anchored, skin integrity
- Where it should be coming out of the nose; checking before feeding
- Making sure you flush the tube; (i.e. order: flush tube with 30mL of water before and after med administration)
- Remember some medications cannot be crushed; may clog up the tube, finely crush as possible when applicable
- Ensure tube is clear; give with water
- If no contraindication about fluid and water intake; be mindful of giving more water (most people in hospital are dehydrated)
- Certain types of tubes that get clogged need to go back to surgery to unclog
21
Q
Administering enteral feeding
A
1) Bolus feeding
- Community/home settings
- Give however much food goes into and drain into stomach
- Have to work up to it
2) Intermittent
3) Continuous
Kangaroo system – has food in one contain and water for flushing in another and machine dolls it out
- Many other machines only have one feeding and you have to flush
22
Q
How to unclog a tube
A
- Bicarb products
- Warm water
- Coca-Cola
- Be careful with using smaller syringe; increase PSI and can damage tip of tube and break it
- Some tubes if clogged have to be surgically removed
23
Q
Best practice in enteral feeding
A
- Preparation, storage and administration
- Hang time
- Selection, verification of location & maintenance of enteral access devices
- Initiation and advancement of EN feeding
- Patient position
- Water safety
- Flushes
- Enteral tube misconnections
- Medication administration (ISMP, 2010)
- Gastric residual volume (GRV)
24
Q
Potential complications of enteral feeding
A
- Aspiration
- Delayed gastric emptying
- Diarrhea
- Constipation
- Occlusion of tube
- If tube not running; start at patient and work way out assessing for kinks, clogs, or compression
- Sometimes you can feel where the clog is, medications or high fat foods
25
Four purposes of NG tubes
1) Feeding (gavage)
2) Decompression
3) Lavage
4) Compression (rare)
26
Feeding/gavage
Installation of liquid nutritional supplements or feedings into the stomach for clients unable to ingest food orally
27
Decompression
- Removal of secretions and gaseous substances from the GI tract to prevent or relieve ABDOMINAL DISTENSION
- Examples of NG tubes used: Salem sump, Levin
- Tube drains by gravity or via suction
Why it might be used?
- Types of bowel surgery
- Removing gases and fluids
- Prevents build up
- Gives bowels a rest
28
Lavage
- Irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation
- Gets contents out of stomach and cleans
29
Compression
- Lacerations in the stomach
- Put in, blow it up and pressure stops the bleeding
- Not common anymore, other ways to deal with bleeding
30
Stay connected - program
- Reducing the risk of medical device tubing misconnections
- A global design standard for tubing connectors will improve patient safety by reducing the incidence of medical device tubing misconnections.
- ENFit connectors available in US, Canada, Puerto Rico
31
Parenteral nutrition
- Client receives nutrients through vascular access [central venous catheter (CVC) or central venous access device (CVAD)]
- Involves IV infusion of highly concentrated solutions of protein (in form of amino acids) and CHO (in form of glucose) as well fat as a lipid emulsion plus electrolytes, vitamins, trace elements and fluid
- Not using the GI tract at all; for whatever reason (need rest, can’t tolerate, etc.)
- Always given through central line; not peripheral - the end of the tip of the catheter ends at the base of the heart
- Reasons being; if they get into peripheral tissue, they will damage it greatly
- Highly concentrated proteins, carbs, lipids, etc.
- Created in pharmacy we do not touch the composition
- Sterile procedure
- Vitamins, supplements added
32
Why give parenteral nutrition
- Non-functional GI tract
- Extended bowel rest
- Preoperative TPN
33
Complications of PN
- Infection
- Air embolism
- Catheter occlusion
- Sepsis
- Electrolyte imbalance
- Hyper- or hypo-glycemia
- Pneumothorax
- Refeeding syndrome
34
Assessment of elimination patterns
- Nursing history
- Physical exam
- Laboratory tests [stool for C & S, stool for O & P, stool for guaiac (FOBT-fecal occult blood test)]
- Fecal characteristics
35
Diagnostic examinations of GI tract
Direct visualization:
- endoscopy
Indirect visualization
- Barium swallow
- Enema
- X-ray (flat plate of abdomen)
- Ultrasound imaging
36
Constipation
Decrease in frequency of BMs accompanied by difficult passage of dry hard stool
37
Common causes of constipation
• Ignoring the urge to defecate
• Sedentary lifestyle, including lengthy bed rest or lack of regular exercise
• A low-fibre diet high in animal fats (e.g., meats, dairy products,
eggs) and refined sugars (e.g., rich desserts)
• A low non-caffeinated fluid intake
• Prolonged and overuse of laxatives
• Polypharmacy
• Comorbidities such as Parkinson’s disease, multiple sclerosis, rheumatoid arthritis, chronic bowel diseases, depression, eating disorders, hypothyroidism, hypocalcemia, or hypokalemia
• Neurological conditions that block the nerve impulse to the colon (e.g., spinal cord injuries, tumours
38
Fecal impaction
- Collection of hardened feces in the rectum
Signs and symptoms:
- Inability to pass stool despite urge to defecate
- Oozing of diarrheal stool
- Loss of appetite
- Abdominal distention with cramping
- Rectal pain
39
Diarrhea
- Increase in the number of stools (several bowel movements per day) and the passage of liquid, unformed feces
Possible causes
- GI bug
- Medications
- New tube feeding
- Lots of reasons
Complications
- Worry about C diff. in hospital (if on antibiotics) – particular odour to diarrhea
- Problematic for older people, immunocompromised people, etc.
- They become very dehydrated very quickly; especially if they are unwell to begin with
Nursing care:
- Rehydrate & correct for electrolyte imbalance
- Administer antidiarrheal medication if appropriate
- Take additional precautions – isolation, PPE, soap & water
- Obtain stool sample if indicated
If incontinent:
- Use incontinence products
- Provide meticulous skin care
- Insert rectal tube if indicated
40
Fecal incontinence
- Inability to control the passage of feces and gas from the anus
- May contribute to social isolation
- Ensure good care of skin; stool can be very acidic and cause quick skin breakdown
- Lots of products available to prevent and treat
41
Flatulence
- Accumulation of flatus (gas) in the lumen of the intestines causing bowel wall to stretch and distend
- Usually expelled through the mouth (belching) or the anus
- Ask people about it
- Can use rectal tube if need to be lessen build up
Signs and symptoms
- Abdominal fullness
- Pain and cramping
42
Hemorrhoids
- Dilated, engorged veins in the lining of the rectum
- May be internal or external
- Can progress to a point that they need to be removed if they interfere with the ability to pass stool
- Products available to help take away itch
43
Promoting regular or normal defecation
- Privacy
- Positioning (sitting upright is best)
- Nutrition (high fiber & fluid intake)
- Regular exercise
- Bowel retraining
44
Administration of suppositories
- Laxatives is least invasive intervention
- Might need to administer suppository
- Different kinds;
- Glycerin (softens the stool)
- Medicated
- Often laxative in evening and suppository or enema in morning
45
Enemas
- An enema is the instillation of a solution into the rectum and sigmoid colon which promotes peristalsis
- The volume instilled breaks up the fecal mass, stretches the rectal wall, and initiates the defecation reflex
46
Types of enemas
1) Cleansing enema:
- Tap Water
- NS (normal saline)
- Hypertonic (Fleet enema)
- Soapsuds (Castile soap)
2) Oil Retention
3) Carminative enema
4) Medicated enema
47
Administering an enema
- Have client lying on left side (Sims position)
- Place waterproof pad under buttocks
- Insert rectal tube
- adult 7.5-10 cm
- child 5-7.5 cm
- infant 2.5-3.75 cm
- If tap water/soap suds/NS enema: instill solution slowly
48
Digital removal of stool
- Digital removal of fecal impaction
- Physician’s order
- Vital signs before and after procedure
- Observe for bradycardia. - Monitor for 1 hour.
- Unpleasant
49
Bowel diversions
- Certain diseases cause conditions that prevent the passage of feces through the rectum
- May also be used to rest bowel (temporary)
- Creation of an artificial opening (stoma) through the abdominal wall
- Surgical opening (ostomy)
- Depending on which part of the intestine is ending at the stoma is the name it’s given
50
Care of clients with ostomies
- Keeping the area clean
- Fitting the right size; one and two piece types
- Often clients are aware of how to care for the ostomy, ask them their preference
51
Factors that can cause anorexia in acute care settings
- The ketosis that accompanies starvation can further suppress appetite, as can the pain that results from surgical procedures and trauma
- Mealtimes are often interrupted or the patient is too fatigued or uncomfortable to eat
- Worries about family, finances, employment , or illness may interfere with getting an adequate diet
- Medications can impair taste, cause nausea, interfere with absorption, or affect metabolism
- Diagnostic testing may disrupt mealtimes or require NPO status
52
Ways that an RN can promote appetite
- Eliminate unpleasant odours
- Provide oral care as needed to remove disagreeable tastes
- Maintain patient comfort
53
Valsalva maneuver
- Pressure can be exerted to expel feces through a voluntary contraction of the abdominal muscles and the diaphragm while maintaining forced expiration against a closed airway
- This action should be avoided by patients, particularly those with heart disease, as the increased intrathoracic pressure, immediate tachycardia, and reflex bradycardia can cause cardiac arrest
54
Factors that influence elimination
- Diet
- Fluid intake
- Physical activity
- Personal bowel elimination habits
- Privacy
55
Complications of digital removal of stool
- Irritation to the mucosa
- Bleeding, perforating the bowel wall
- Stimulation of the vagus nerve, which result sin a reflex slowing of the HR
56
Proper positioning for using a bedpan
- Patient is positioned high in bed
- Raise the patient’s head about 30 degrees to prevent hyperextension of the back and to provide support to the upper torso.
- Raise the hips by bending the knees and lifting the hips upward
