Week 11- Insertion of NG tube for feeding Flashcards Preview

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Flashcards in Week 11- Insertion of NG tube for feeding Deck (48):
1

What is enteral feeding?

By definition, enteral means “within or by way of the gastrointestinal tract”. For our class enteral means “tube feeding”. Enteral nutrition refers to the provision of nutrients into the gastrointestinal tract via a tube, catheter, or stoma to deliver nutrient distal to the oral
cavity when oral intake is inadequate (1)

2

What are the indications for enteral nutrition? (Island Health)

NPO > 5 days
 Inadequate oral intake > 7 days
 Ventilated,  LOC
 Catabolic (e.g. severe trauma or burn)
 Post-operative major GI surgery (Whipples, SBS)
 Severe malnutrition and weight loss
 Radiation Enteritis
 Severe Inflammatory bowel disease (Crohns, Ulcerative Colitis)
 Severe dysphagia and patient not safe for oral intake
 Acute or chronic pancreatitis
 Eating disorders
 Diabetic gastroparesis
 Severe hyperemesis gravidarum with weight loss

3

What are the contraindications for enteral feeding?

The gastrointestinal tract is not functioning or inaccessible
 Complete gastric or intestinal obstruction if access cannot be placed distal to
obstruction
 Prolonged refractory ileus
 Patient is hemodynamically unstable
 Severe refractory diarrhea or vomiting
 High output enteric fistulas (> 500 mL/day)
 Abdominal distention
 Short bowel (> 70 % of small bowel removed or non functional)
 Radiation enteritis
 Aggressive nutritional support is not desired by the patient or legal guardian
 The patient’s medical prognosis does not warrant aggressive nutritional support

4

What is the benefit of enteral nutrition vs parenteral nutrition (e.g. TPN)?

Maintains gut mucosa integrity
 Limits bacterial translocation
 Prevents pancreatic and biliary flow dysfunction
 Lower risk for infection
 Lower cost

5

What are the purposes of GI intubation (e.g. nasogastric tube, Gtube, etc)

Decompress the stomach (decompression )
Lavage the stomach (irrigation)
Diagnose GI disorders
Administer medications and feeding(gavage)
Treat an obstruction
Compress a bleeding site
Aspirate gastric contents for analysis
Pre and post surgery

6

What are the types of GI intubation tubes?

Orogastric tubes:
Usually large bore tubes with wide openings.
More common in ER settings

Gastric tubes
Levin
Sump

Enteric tubes
Feeding tubes
(the Focus of this week

7

What are the different types of enteric tubes (feeding tubes)

1) Nasogastric/ Orogastric feeding tube

2) Nasointestinal

3) Gastrostomy

4) Jejunostomy

8

What is the purpose of enteric feeds/ advantages? (PPT)

Meets nutritional requirements when oral intake is inadequate or not possible:
Ventilated with LOC
Severe inflammatory bowel disease
NPO for more than 5 days
Acute or chronic pancreatitis
Eating disorders
Severe hyperemesis

Advantages:
Safe and cost-effective
Preserves GI integrity
Preserves the normal sequence of intestinal and hepatic metabolism
Maintains fat metabolism and lipoprotein synthesis
Maintains normal insulin and glucagon ratios

9

What are some key points for tube feeding? (PPT + i added one comment ;) )

Determine correct formula for patient needs
Determine what Tube
Nasogastric tubes (if less than 30 days)
Gastrostomy or jejunostomy tubes for long-term feeding
Individualized care plan
Changing the equipment

Methods in administration
Intermittent /Continuous feedings
Bolus feeding
Kangaroo pump/ Gravity

10

What is the nursing care for the patient with a nasogastric tube? (PPT)

Patient teaching and preparation
Tube insertion
Confirming placement
Securing the tube
Monitoring the patient
Maintaining tube function
Oral and nasal care
Monitoring, preventing, and managing complications
Tube removal

11

How do we confirm placement? (PPT)

Observe the insertion.
Check the contents ( the aspirate for color & ph). Listen (insert air) traditional
X RAY IS GOLD STANDARD AND THE ONLY CERTAIN WAY TO CONFIRM PLACEMENT.
Measure tube length (usually markings on tube)
Secured with tape
Why do we need to confirm placement ?

12

Where is tube feeding delivered to?

Tube feeding is delivered to stomach or to distal duodenum or proximal jejunum (indicated when esophagus or stomach need to be bypassed or aspiration risk

13

What is Dumping Syndrome and how can it be avoided? (readings)

Feeding formulas with high osmolarity may lead to dumping syndrome
Fluid balance is maintained by osmosis ( body fluids are usually 300 mmol/kg)
Proteins are large particles and have a less osmotic effect , fats do not enter water so have no osmotic effect
AA and carbs and electrolytes have great osmotic effect
When a concentrated solution of high osmolarity is taken, the water moves to the stomach and intestines from fluid surrounding the organs/vasculature and pt feels fullness, nausea and diarrhea -> dehydration hypotension and tachycardia ( DUMPING SYNDROME)
Can be avoided by starting with more dilute substances and slowly moving more concentrated can alleviate this problem

14

What are some examples of formulas available for tube feeding?

Various formulas for tube feedings available:
Commercially prepared polymeric formulas ( high molecular weight, have protein, carbs and fats ( e.g. Ensure (meal replacement but this is a popular one))

Chemically defined formulas ( vivonex ) contain predigested , easy to absorb nutrients

Modular products contain only one major nutrient ( protein)
Formulations for certain diseases ( renal failure : high cal, low electrolytes, COPD: low carb, high fat )

15

What are the different ways of administering tube feeds? (readings)

Could be intermittent gravity drip,
intermittent bolus,
continuous on pump( into small intestine - preferred for pt at risk for aspiration )
or cycle feeding ( infusion at faster rate over shorter time, potentially at night, may be used to wean off tube feedings to oral)

* i think there was another one mentioned in class (but not sure), maybe scheduled (e.g. 8am 12pm, 4pm) versus every 4 hours (more flexibility).

16

to Ensure patency, decrease chance of bacterial growth, crusting or occlusion of the tube what do you do?

at least 30-50mL (note ppt says 30 after and before, as well as 15ml inbetween meds) of water (sterile if immunocompromised) or NS is administered in each other following instances:
Before and after meds and feedings
After checking for gastric residuals/pH
Every 4-6 hr with continuous
If tube feeding is discontinued or interrupted
When tube is not being used ( twice daily admin is recommended)

17

Why would you use a 30mL or larger syringe with a small bore feeding tube?

Be careful with small bore feeding tubes are used that you are using a 30mL or larger syringe to avoid too much pressure

18

How often do you change the tubing on closed-system feeds and open-system feeds?

Open system feeding comes with feeding container and tubing are changed every 24-72 hr to avoid bacterial contamination
Feeding formula in one bag should never exceed what can be infused in a four hr period

Closed delivery use a pre-filled sterile container that is spiked with enteral tubing
Bag holding formula for the closed system can be hung safely for 24-48 hr

19

What consistency of stool can be expected for feeds?

Pasty unformed stools are expected with enteral therapy

20

What are some other reasons for diarrhea besides dumping syndrome?

Other reasons for diarrhea besides dumping syndrome:
Contaminated formula
Malnutrition
Meds ( Abx)
C diff

21

How do you promote hydration (feeding)?

Promoting hydration: water is given every 4-6 hr and after feedings

22

What do anticoagulation and bleeding disorders pose a risk for?

anticoagulation and bleeding disorders pose a risk for epistaxis (bleeding from the nose) during nasal tube placement, the health care provider may order platelet transfusion or other corrective measures before tube insertion.

23

How do you insert a nasogastric feeding tube?

-Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet.
- Perform hand hygiene.
 Position patient upright in high Fowler’s position unless contraindicated. If patient is comatose, raise head of bed as tolerated in semi-Fowler’s position with head tipped forward, chin to chest. If necessary have an assistant help with positioning of confused or comatose patients. If patient is forced to lie supine, place in reverse Trendelenburg’s position (head is 15-30 degrees higher than feet)
 Apply pulse oximeter and measure vital signs.
 Determine length of tube to be inserted and mark location with tape or indelible ink.
a Measure distance from tip of nose to earlobe to xyphoid
process of sternum (see illustration).
 Prepare NG or nasoenteric tube for intubation.
a Inject 10 mL of water from 30- to 60-mL Luer-Lok or
catheter-tip syringe into the tube.
b If using stylet, make certain that it is positioned securely within tube.
Cut hypoallergenic tape 10 cm (4 inches) long or prepare membrane dressing or other tube fixation device.
 Apply clean gloves.
Dip tube with surface lubricant into glass of room-temperature water or apply water-soluble lubricant
 Explain the step and gently insert tube through nostril to back of throat (posterior nasopharynx). This may cause patient to gag. Aim back and down toward ear (see illustration).
 Have patient flex head toward chest after tube has passed
through nasopharynx.
 Encourage patient to swallow by giving small sips of water or ice chips. Advance tube as patient swallows.
 Reemphasize need to mouth breathe and swallow during procedure.
 When tip of tube reaches carina (approximately 25 to 30 cm [10 to 12 inches] in an adult), stop and listen for air exchange from distal portion of tube.
Advance tube each time patient swallows until desired length has been passed (see illustration).
Check for position of tube in back of throat with penlight and tongue blade.
 Temporarily anchor tube to nose with small piece of tape.
Keep tube secure and check placement by aspirating stomach contents to measure gastric pH
Anchor tube to patient’s nose, avoiding pressure on nares. Mark exit site on tube with indelible ink. Select one of the following options for anchoring:
a Apply tape:
(1)  Apply tincture of benzoin or other skin adhesive on tip of patient’s nose and allow it to become “tacky.”
(2)  Remove gloves and split one end of tape lengthwise 5 cm (2 inches).
(3)  Place intact end of tape over bridge of patient’s nose. Wrap each of the 5-cm strips in opposite directions around tube as it exits nose (see illustration).
b Apply membrane dressing or tube fixation device:
(1) Membrane dressing:
(a) Apply tincture of benzoin or other skin protector
to patient’s cheek and area of tube to be secured. (b) Place tube against patient’s cheek and secure tube with membrane dressing, out of patient’s line of
vision.
(2) Tube fixation device:
(a) Apply wide end of patch to bridge of nose (see illustration).
(b) Slip connector around feeding tube as it exits nose (see illustration).
20  Fasten end of NG tube to patient’s gown using clip (see illustration) or piece of tape. Do not use safety pins to secure tube to gown.
21  Assist patient to comfortable position. Remove gloves and perform hand hygiene.
 Obtain x-ray film of chest/abdomen. (within two hours, but island health wants nurses to put an xray req in, call to find out when the appt time is, then insert the nasogastric tube just before, because it's really uncomfortable having it in with the metal sylet).
 Apply clean gloves and administer oral hygiene (see Chapter 17). Clean tubing at nostril with washcloth dampened in mild soap and water.
 Remove gloves, dispose of equipment, and perform hand hygiene.


24

How do you remove the nasogastric tube?

Tube Removal
1  Verify health care provider’s order for type of tube and enteric feeding schedule.
2  Gather equipment: Disposable pad, tissues, clean gloves, disposable plastic bag or receptacle.
3  Explain procedure to patient.
4  Perform hand hygiene. Apply clean gloves.
5  Position patient in high Fowler’s position unless contraindicated.
6  Place disposable pad or towel over patient’s chest.
7  Disconnect tube from feeding administration set if present.
8  Remove tape or tube fixation device from patient’s nose. Unclip tube from patient’s gown.
9  Instruct patient to take deep breath and hold it.
10  Kink end of tube securely by folding it over on itself.
11  Completely withdraw tube by pulling it out steadily and smoothly. Dispose of it into appropriate receptacle.
12  Offer tissues to patient to blow nose.
13  Offer mouth care.
14  Remove gloves; perform hand hygiene

25

What do you record/ report?

Record and report type and size of tube placed, location of distal tip of tube, patient’s tolerance of procedure, and confirmation of tube position by x-ray film examination.
Record removal of tube and patient’s tolerance.
Report any type of unexpected outcome and the interventions
performed.
Tube removal: record patient’s level of comfort.

26

What teaching would you do with a feed patient (nasogastric tube)

• Instruct patient or family caregiver to offer oral hygiene frequently and keep patient’s lips lubricated.
• Teach patient or family caregiver to report tension on feeding tube or displacement of tape or tube fixation device; instruct patient or caregiver to stabilize the tube and call for help.

27

What are the pediatric considerations for a feeding tube?

The distance from nose-to-ear-to–mid-umbilicus better predicts insertion length for gastric tube placement in neonates and children than traditional nose-to-ear-to-xyphoid measurements
X-ray film confirmation of tube position is not routinely per- formed because of the radiation risk.
• Routine flushing of tubes is not recommended in pediatric patients.
• When inserting a feeding tube in an infant, observe for vagal stimulation evidenced by a decreased heart rate.

28

How do nurses verify placement of NG tube? (readings)

Nurses insert small-bore feeding tubes nasally for intermittent or continuous feeding.
It is possible for the tip of a feeding tube to move or migrate into a different location (e.g., from the stomach into the intestine or esophagus, from the intestine into the stomach).

Although all tubes should be marked to document correct position, tube dislocation can sometimes occur without any external evidence that the tube has moved.

The risk of aspiration of regurgitated gastric contents into the respiratory tract increases when the tip of the tube accidentally dislocates upward into the esophagus.

Following initial x-ray film verification of correct feeding tube position, you must monitor the tube to ensure that the tube tip remains in the intended site.

Based on a patient’s clinical condition and agency policies, you check feeding tube position at regular intervals (often every 4 to 6 hours) and before administering formula or medications through the tube

Monitor the external length of the tube and observe the appearance, volume, and pH of fluid aspirated through it.
The color of the fluid can help differentiate gastric from intestinal placement. Because most intestinal aspirates are stained by bile to a distinct yellow color and most gastric aspirates are not, the difference in color can often distinguish the site

Testing the pH of an aspirate at the bedside using pH paper offers some information regarding the position of a feeding tube, but results are not reliable during continuous feeding and should be used in combination with other indicators with careful assessment

Do not insufflate (blow) air into tube to check placement ** it says not to do this in readings, but on the ppt it says this is a traditional way of checking, and I did see some nurses do this while using a stethoscope).

29

What assessments are done with an NG tube?

1  Review agency policy and procedures for frequency and method of checking tube placement. Do not insufflate air into tube to check placement.
2  Observe for signs and symptoms of respiratory distress during feeding: coughing, choking, or reduced oxygen saturation.
3  Identify conditions that increase risk for spontaneous tube migration or dislocation:
Altered level of consciousness, agitation.
Retching/vomiting/coughing.
nasotracheal suctioning
** are they on a gastric acid inhibitor?? This would eliminate usefulness of pH measurements by buffering the pH of stomach

30

How is confirmation of tube implemented?

NOTE: i heard from my nurse friends they don't actually do this in clinical. They do the initial x-ray and tube tip is weighted so they've never had it displace. They also said they rarely put any air in bc gastric contents spill out right away when they do.

1  Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet.
2  Prepare equipment at patient’s bedside, perform hand hygiene, and apply clean gloves.
3  Verify tube placement at the following times:
a  For intermittently tube-fed patients, test placement
immediately before each feeding and before medications.
b  Follow agency policy regarding pH testing for patients receiving continuous tube feeding. AACN (2010) recommends that continuous feedings be stopped for several
hours to obtain reliable pH readings.
c  Wait to verify placement at least 1 hour after medication
administration by tube or mouth.
4  Draw up 30 mL of air into a 60-mL syringe and attach to end
of feeding tube. Flush tube with 30 mL of air before attempting to aspirate fluid. Repositioning patient from side to side is helpful. In some cases more than one bolus of air is necessary.
5  Draw back on syringe slowly and obtain 5 to 10 mL of gastric aspirate Observe appearance of aspirate (see Fig. 31-2).
6  Gently mix aspirate in syringe. Expel few drops into clean medicine cup. Measure pH of aspirated GI contents by dipping pH strip into fluid or by applying a few drops of fluid to strip. Compare color of strip with color on chart (see illustration) provided by manufacturer.
a  Gastric fluid from patient who has fasted for at least 4 hours usually has pH range of 5.0 or less.
b  Fluid from tube in small intestine of fasting patient usually has pH greater than 6.0
c Patient with continuous tube feeding may have pH of 5.0 or higher
d pH of pleural fluid from tracheobronchial tree is generally greater than 6.0
7  If after repeated attempts it is not possible to aspirate fluid from a tube that was confirmed by x-ray film to be in desired position and if there are no risk factors for tube dislocation, monitor external length of tube and observe patient for evidence of respiratory distress
8  Irrigate tube
9  Remove and dispose of gloves and supplies in appropriate receptacle. Perform hand hygiene.

31

What is the most common reason for feeding tube occlusion?

Curdled enteral formula and improperly crushed medications are the most common causes of feeding tube occlusion

32

What is the assessment and procedure for irrigating a feeding tube?

1  Inspect volume, color, and character of gastric aspirates (if obtainable).
2  Assess bowel sounds.
3  Note ease with which tube feeding infuses through tubing.
4  Monitor volume of enteral formula administered during a shift and compare with ordered amount.
5  Refer to agency policies regarding routine irrigation, usually every 4 to 12 hours


IMPLEMENTATION
1  Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet.
2  Perform hand hygiene, prepare equipment at patient’s bedside, and apply clean gloves.
3  Verify tube placement (see Skill 31-2) if fluid can be aspirated for pH testing.
4  Irrigate routinely before, between, and after final medication (before feedings are reinstituted); and before an intermittent feeding is administered.
5  Draw up 30 mL of water in syringe (see illustration). Do not use irrigation fluids from bottles that are used on other patients. Patient should have an individual bottle of solution.
6  Change irrigation bottle every 24 hours. Irrigation trays, which hold both irrigation fluid and syringe, are considered open systems and may be more easily contaminated than sterile water bottles.
7  Kink feeding tube while disconnecting it from administration tubing or while removing plug at end of tube (see illustration).
8  Insert tip of syringe into end of feeding tube. Release kink and
slowly instill irrigation solution (see illustration).
9  If unable to instill fluid, reposition patient on left side and try again.
10  When water has been instilled, remove syringe. Reinstitute tube feeding or administer medication as ordered. Flush each medication completely through tube (see Skill 21-2).
11  Remove and discard gloves; dispose of supplies in appropriate receptacle. Perform hand hygiene

33

What is the assessment, implementation and evaluation for administering enteral nutrition? (p.s. this is from the textbook and my nurse friend said they don't actually do the GRV on her unit. I also saw some contradictory information about it online)

Administering enteral nutrition: nasoenteric, gastrostomy, jejunostonmy tube
ASSESSMENT
1  Assess patient’s clinical status to determine potential need for tube feedings: Decreased level of consciousness, nutritional deficits, head or neck surgery, facial trauma, or impaired swallow. Consult with nutrition support team or health care provider.
2  Assess patient for food allergies.
3  Perform physical assessment of abdomen, including auscultation
for bowel sounds before feeding (see Chapter 6).
4  Obtain baseline weight and review serum electrolytes and blood glucose measurement. Assess patient for fluid volume excess or deficit, electrolyte abnormalities, and metabolic abnormalities (e.g., hyperglycemia).
5  Verify health care provider’s order for type of formula, rate, route, and frequency.


IMPLEMENTATION
1  Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient’s identification bracelet.
2  Perform hand hygiene. Apply clean gloves (Bankhead et al., 2009).
3  Obtain formula to administer:
a Verify correct formula and check expiration date; note
condition of container.
b Provide formula at room temperature.
4  Prepare formula for administration:
a Use aseptic (clean) technique when manipulating components of feeding system (e.g., formula, administration set,
connections).
b  Shake formula container well.
Clean top of canned formula with alcohol swab before
opening it (Bankhead et al., 2009).
c  For closed systems, connect administration tubing to
container. If using open system, pour formula from brick pack or can into administration bag
5  Open roller clamp and allow administration tubing to fill. Clamp off tubing with roller clamp. Hang container on intravenous (IV) pole.
6  Place patient in high-Fowler’s position or elevate head of bed at least 30 degrees (preferably 45 degrees). For patient forced to remain supine, place in reverse Trendelenburg’s position. (head of bed is higher than feet)
7  Verify tube placement (see Skill 31-2). Observe appearance of aspirate and note pH measure.
8  Check gastric residual volume (GRV) before each feeding (for bolus and intermittent feedings) and every 4 to 6 hours (for continuous feedings)
a Draw up 10 to 30 mL air into syringe and connect to end of feeding tube.
b  Inject air into tube. Pull back slowly and aspirate total amount of gastric contents (see illustration).
c  Return aspirated contents to stomach unless volume exceeds 250 mL (see agency policy)
d  Do not administer feeding when a single GRV measurement exceeds 500 mL or when two measurements taken 1 hour apart each exceed 250 mL
e  Flush feeding tube with 30 mL water (see Skill 31-3).
9  Before attaching feeding administration set to feeding tube, trace tube to its point of origin. Label administration set, “Tube Feeding Only.”
10  Intermittent gravity drip:
a  Pinch proximal end of feeding tube and remove cap. Connect distal end of administration set tubing to feeding tube and release tubing.
b  Set rate by adjusting roller clamp on tubing or attach tubing to feeding pump. Allow bag to empty gradually over 30 to 45 minutes (see illustration). Label bag with tube-feeding type, strength, and amount. Include date, time and initials
c Change bag every 24 hours

11 Continuous drip method:
a  Connect distal end of administration set tubing to feeding tube as in Step 10a.
b  Thread tubing through feeding pump; set rate on pump and turn on (see illustration).
12  Advance rate of tube feeding gradually, as ordered.
13  Flush tubing with 30 mL water every 4 hours during continuous feeding (see agency policy), before and after an intermittent feeding. Have registered dietitian recommend total free water requirement per day and obtain health care provider’s order (see Skill 31-3).
14  When patient is receiving intermittent tube feeding, cap or clamp end of feeding tube when not being used.
15  Rinse bag and tubing with warm water whenever feedings are interrupted. Use new administration set every 24 hours.
16  Dispose of supplies and perform hand hygiene

EVALUATION
1  Measure GRV per policy, usually every 4 to 6 hours, and ask if nausea or abdominal cramping is present.
2  Monitor intake and output at least every 8 hours and calculate daily totals every 24 hours.
3  Weigh patient daily until maximum administration rate is reached and maintained for 24 hours; then weigh patient 3 times per week.
4  Monitor laboratory values.
5  Observe patient’s respiratory status.
6  Auscultate bowel sounds.
7  For tubes placed through abdominal wall, inspect site for signs
of impaired skin integrity.

34

What do you know about enteral feeds for infants? (list what you know and compare)

Nasogastric, orogastric tube feeding
Supply adequate nutrition to an infant who is unable to suck, tires easily, cannot swallow or chew
Enteral over parenteral
Preserve stomach mucosa and decrease risk of infection, infiltration
Easy to manage at home
Aka gavage feedings

Debate over if tube should go in an infants mouth because tube may obstruct nasal passage
Infants only breath through nose
Most tubes will be inserted through their mouth
Orogastric insertion can decrease possibility of striking vagal nerve in the back of throat, causing brady cardia
For older children, insertion via nose more comfortable
To prevent irritation/ulcer on nose, always tape nasogastric tubes to the child's cheek rather than forehead to secure it in place
Tubes are radiopaque= can be confirmed on x-ray
Nutrition formula used should be room temp
Elevate child upper trunk before feeding
30-40 degrees, semi fowlers
So fluid will flow downward to stomach and not up into the esophagus= aspiration
To reduce aspiration in infants, place in car seat or hold them upright
For small infants, before feeding it is often necessary to aspirate stomach contents to see whether infant is absorbing the quantity of the fluid given as well as confirmation of tube placement
After noting the amount and type of fluid aspirated, replace stomach contents so child does not lose electrolytes
Attach syringe to the tube and allow formula to flow by gravity into tube
Don’t use barrel of syringe to force feeding forward in order to prevent reflux and aspiration
Most infants enjoy a soother while eating to mimic the sucking reflux
Also helps maintain/strengthen sucking reflux for later when the child returns to oral feedings
At end of feeding, flush tube with 1-5 ml of water to clear tube of feeding solution
Prevent blockage, maintain patency
Keep child's head elevated for 1 hour after feeding to prevent esophageal reflux
Provide mouth care at least twice a day to encourage salivation
Mouths will become dry and prone to formation of mucosal ulcers

35

Therapeutic play can be divided into three types:
____, _____, ______?

Therapeutic play can be divided into three types:
Energy release
Dramatic play
Creative play

36

What is energy release play? (children)

Energy release
Release energy by pounding, hitting, running, punching and shouting
Help release anxiety
Toddlers enjoy pounding pegs with hammers
Or pretending to cut wood
Give clay to punch and destroy or allow school age child to punch balloon

*best for toddlers

37

What is dramatic play (children)?

Dramatic Play
Acting out an anxiety producing emotion
Most effective with preschool children because they are at the peak of imagination
Use common healthcare equipment
Dolls, doll beds, stethoscopes, IV equipment, syringes, masks and gowns
Puppets of doctors, nurses, parents and children, help children express their feelings
Anatomical correct dolls may help children discuss sexual mistreatment
Play with children at the beginning of illness to see if children communicate feelings about illness
Play with children during illness to describe procedures
Repeat play after any painful or traumatic procedure ex surgery
If play sessions reveal fears, play sessions should be scheduled at least once daily
Allow play to be nondirective
Empowers child
Less fearful
Watch for unusual use of equipment
Ex. Thermometer in dolls eye
Requires further patient teaching
Ask for clarification if child says something such as "I'm giving an injection to all the bad dolls"
This explains how the child perceives injections
Do not rush to reassure children because reassurance can infer that the children should not ask any more questions
Do not reply on parents to do the patient teaching
Ensure you are totally thorough with child
Prepare them well for procedure
Children over 9 find playing with dolls too childish to be of benefit
They enjoy instead to handle syringes, equipment
Active handling helps to eliminate fear because it identifies exactly what the child has to face, meets their concrete learning needs
*best for school age* preschool

38

What is creative play?

Creative Play
Some children are too angry to act out their feelings through dramatic play
May be able to draw a picture instead
Give child blank paper, and crayons
Tell child to draw a picture of themselves
May not draw a leg because they think the doctors are amputating the leg
Draw a child behind bars: punishment from doctors and nurses
Explain that they are not being punished
Child may draw a picture involving death
Discuss this with child
Older children may prefer to make lists of procedures/experiences they like, dislike

39

When should an NG tube be confirmed by X-ray?

Confirmation of feeding tubes MUST be verified by Xray and documented by physician
Intial insertion
Re-insertion
Suspected migration
Tube displacement greater than 10cm

40

What are the three best ways to check for placement (not including xray)?

Measurement of tube length
Visual assessment of the aspirate
Obtain gastric aspirate /PH measurement - What PH do you expect from gastric contents?
The pH of gastric aspirate is acidic (1-5)
The pH of intestinal aspirate is 6 or higher.
The pH respiratory aspirate is 7 or greater

41

What do you do after the NG tube has been confirmed by x-ray?

Flush tube through stylet connector (10cc H20)

Remove stylet

Mark tube at nare exit point

Measure external segment of tube
(nostril to end of tube)

Assess client and commence feeds as ordered

42

What steps are involved in administering enteral feedings?

Review the individualized care plan(type of formula, feeding schedule( intermittent /continuous )&rate )
Asses patient and check for placement
Client positioning
Check the equipment (Pump , jug ,syringe & water)
Check the formula kind & expiry
Calculate the rate according to the care plan and perform the proper checks
Explain procedure and what is expected for patient / family
Be aware of the Residual checks and when holding of feeds

43

What is the ongoing monitoring and maintenance of an NG tube?

General assessment :How is the patient tolerating the feeds?
Follow the care plan(intermittent /continuous)and check for residual and tolerance
Intake and output
Nutritional status
Hydration
Digestion
Kidney function
Muscle function
Bowel function
Medications that may be affecting the nutritional intake
Does the dietary régime fulfill the patients needs?
Weight changes – monitor gain or loss
Administer medications safely
Patients positioning head of bed elevated to 30 - 45 degrees
Monitor for complications
Administer medications safely
Patients positioning head of bed elevated to 30 - 45 degrees
Monitor for complications
ASSESS TUBE PLACEMENT
Before each feed
Before medication delivery
And once a shift
If aspiration is suspected the FEED IS STOPPED
Suction and assess patient
Notify physician

44

If you suspect your patient is aspirating what do you do?
a) call the physician
b) req for an x-ray
c) stop the feed
d) suction and assess patient

c) stop the feed, then suction and assess, then call the physician

45

What are some general rules for administering meds through a feeding tube?

GENERAL RULES:
The medications need to be crushed
Mixed with small amount of water (30ml) (ppt says 15-30 luke warm water)
Flush of water between each medication (15ml)
Given individually/separately
Liquid form – when possible
DO NOT crush sustained /delayed release meds
Cytotoxic meds should not be crushed – talk to pharmacy
DO NOT mix medications – they can set like cement and clog tube
Consult with pharmacy and use a prepared elixir whenever possible

46

What were the complications highlighted in class?

Diarrhea (common) nausea& vomiting , gas/ bloating/cramping , constipation
Tube displacement, tube obstruction, residue of medications, nasopharyngeal irritation
Fluid Volume& Electrolyte imbalances (mainly deficits)
Aspiration pneumonia
Tissue damage/Mucous membranes
Dehydration and azotemia
Metabolic: hyperglycemia & dumping syndrome

47

What are some ways to prevent dumping syndrome?

WAYS TO PREVENT DUMPING SYNDROME.
Slower delivery
Room temperature feed
Continuous method
Advise patient to remain sitting up for an hour after a feed
Balance water administered with a feed…maybe too much at one time? Consult with dietitian

48

What is refeeding syndrome?

Is a potentially fatal complication that occurs when a malnourished patient begins receiving nutrition again .
Patients at risk :cancer patients undergoing chemotherapy, malnourished elderly people, homeless or alcoholic patients who haven’t eaten in several days, and anorexia nervosa.
During starvation mode, the body’s metabolism reduced and several hormonal and metabolic changes takes place to save energy to maintain body function and fat becomes the main energy source ..
Once refeeding begins
Formula usually high in protein and carbohydrates which increase glucose level and release of insulin .
Insulin causes uptake of glucose ,phosphate ,potassium and magnesium into the cells which lead to:
Hypophosphatemia : hypotension ,seizures, anemia and respiratory distress
Hypokalemia: delirium , resp distress
Hypomagnesaemia :seizures ,anemia ,GI symptoms
Arrhythmia ,neuromuscular disturbances ,weakness ,lethargy
Refeeding should be started at a low level, monitoring patient closely , lab checks before and during and correction of electrolyte imbalance.