Week 2 Flashcards by Divya Adukuzhiyil

When someone is admitted, what do we assume about the person?

When someone is admitted, we assume they are at a nutritional risk.

All critically ill patients are assumed to be at nutritional risk

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All critically ill patients are assumed to be at nutritional risk

Around what percent?

≈ 50% on admission to the hospital

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What is an important part of overall care plan for patient?

Nutritional support is an important part of overall care plan

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Utilization of Nutrients

What organs or organ parts are involved?

Duodenum

Jejunem

Ileum

Colon

Pancreas

Liver

Gallbladder

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Utilization of Nutrients

Duodenum: What does it do? What empties here?

Pancreas and liver empty here
Absorbs minerals

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Utilization of Nutrients

Jejunum: What occurs here?

Glucose and water-soluble vitamins absorbed

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Utilization of Nutrients

Ileum: What occurs here?

Protein broken down and absorbed

Absorbs fat-soluble vitamins

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Utilization of Nutrients

Colon: What is formed here? What is absorbed?

Vitamin K formed

Absorbs Na+ and K+

Water reabsorbed

Absorption of short-chain fatty acids

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Utilization of Nutrients

Pancreas: What does it do?

Secretes digestive enzymes

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Utilization of Nutrients

Liver: What does it do?

Multiple functions like detoxification

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Utilization of Nutrients

Gallbladder: What does it do?

Assists in emulsifying fats

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Nutritional Assessment:

What does it provide a baseline for?

Provides baseline subjective and objective data regarding nutritional status

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Nutritional Assessment:

What does it determine and identify and establish?

Determines nutritional risk factors

Identifies nutritional deficits

Identifies medical, psychosocial, and socioeconomic factors

Establishes nutritional needs

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Nutritional Assessment:

What should be considered?

CONSIDER:

access to healthy food, Meals-on-Wheels, lack of support, mobility, & transportation, social isolation, lower income, poorly fitting dentures or missing teeth

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Nutritional Assessment

Subjective and objective data in ICU patient

Gag reflex

Dysphagia

Adequate dentition

Oral mucosa

Hydration status

Patient’s medical history

Malabsorption syndrome

Laboratory values

Input and output

Daily weight

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Nutritional Therapy Goal: What is it?

Goal is nutritional support consistent with metabolic needs and disease process while avoiding complications

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Nutritional Therapy Goal:

What kind of patient requires nutritional support?

Any patient who cannot meet needs orally for 3 or more days requires nutritional support:

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Nutritional Therapy Goal:

Any patient who cannot meet needs orally for 3 or more days requires nutritional support:

What are examples of this type of patient?

Diminished cognition

Sedation

Endotracheal intubation

Post-Stroke: impaired swallowing

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Nutritional Therapy Goal:

Referral to Nutritionist: What does a nutritionist do?

Patient’s calorie, protein, and fluid needs

Intake targets

Route of administration

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Nutritional Therapy Goal

Set measurable short- and long-term goals

What are examples of these types of goals?

Weight gain

Stable laboratory values: pre-albumin, albumin, transferrin

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Enteral Nutrition: What is it?

Delivery of nutrients to gastrointestinal (GI) tract

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What is the preferred method of feeding people who are at nutritional risk?

Enteral Nutrition- Delivery of nutrients to gastrointestinal (GI) tract

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Why is the enteral nutrition the preferred method of feeding people who are at nutritional risk?

Lower risk of infection

Less expensive

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Enteral Nutrition

What is the long term nutrition?

Long-term nutrition: PEG or jejunostomy

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Enteral Nutrition What type of tubing goes through the GI tract?

All types of tubing goes through the GI tract.

Guidelines for Enteral Feeding Short-term enteral feeding includes:

Nasogastric route Nasoduodenal route Nasojejunal

Guidelines for Enteral Feeding Long-term enteral feeding includes:

Gastrostomy tube Jejunostomy tube

Placing Nasoenteric Tubes: Who is it placed by?

Placed by skilled nurses or physicians

Placing Nasoenteric Tubes: When placing, what do they follow?

Follow institutional policy.

Placing Nasoenteric Tubes: How does the measurement work?

Measure the distance from the tip of the nose, to the earlobe, to the tip of the xiphoid process.

Placing Nasoenteric Tubes: What kind of things are used to insert the tube?

Topical anesthetic or water-soluble lubricant

Placing Nasoenteric Tubes: How should the patient be positioned?

Place the patient in high Fowler’s position and flex the patient’s head (if not contraindicated).

Placing Nasoenteric Tubes: What should be lubricated?

Lubricated tip

Placing Nasoenteric Tubes What should you ask the patient to do?

Ask the patient to swallow repeatedly.

Placing Nasoenteric Tubes How should you advance the tube?

Turn the patient to the right lateral decubitus position with the head of the bed at a 30- to 45-degree angle to advance the tube.

Placing Nasoenteric Tubes Why do you need the patient cooperation?

You ask the patient to swallow so the tube doesn’t go in the trachea.- You need patient’s cooperation

Confirming Placement What should you measure? What should you auscultate? What should you visualize?

Measurement of tube length Auscultate placement LUQ Visual assessment of aspirate pH measurement of aspirate

Confirming Placement: What is the gold standard for confirming initial tube placement before initiating feeding?

Abdominal radiograph is the gold standard for confirming initial tube placement before initiating feeding.

Securing the Nasogastric Tube: What should you consider?

Consider mobility Patient LOC, state of agitation.

Securing the Nasogastric Tube: What must be auscultated?

Auscultate placement Q 4 hrs., pre-medications

Securing the Nasogastric Tube: What must tube be pinned to?

Wrap adhesive tape around tube and pin to pt gown. DO NOT PIN TO PILLOW CASE

Securing the Nasogastric Tube: What must be retaped?

Re-tape if wet

Enterostomal Feeding and Feeding Tubes Indicated when:

Therapy will last a month or more Nasal route is contraindicated Patient has impaired swallowing Oropharynx, larynx are obstructed

Percutaneous esophageal gastrostomy (PEG) tube How should HOB be?

HOB at least 30 degrees

Percutaneous esophageal gastrostomy (PEG) tube What should be done around the insertion site?

Assess & clean skin around insertion site

Percutaneous esophageal gastrostomy (PEG) tube What must be done after each intermittent feeding?

Flush NG tube or PEG after each intermittent feeding

Percutaneous esophageal gastrostomy (PEG) tube How should meds be given?

Crush medications except enteric coated tablets.

Percutaneous esophageal gastrostomy (PEG) tube How should Time-release tablets be given?

Time-release tablets: some can be opened; cannot be crushed because doing so may release too much drug too quickly (overdose); always check with pharmacist if in question

Tolerance of Enteral Nutrition

Presence of bowel sounds in four quadrants, as determined by auscultation Presence of bowel motility or bowel movements Palpation of a soft abdomen Percussion of the abdomen revealing tympanic findings

Signs of Intolerance of _____.

Nausea or vomiting Absent bowel sounds Abdominal distension Cramping Diarrhea

Tolerance of Enteral Nutrition How long should you listen for bowel sounds?

You need to listen to FIVE minutes.

Complications of Enteral Nutrition

Gastrointestinal Mechanical Metabolic Infectious

Complications of Enteral Nutrition Gastrointestinal

High residuals, nausea, vomiting, bloating, diarrhea, constipation

Complications of Enteral Nutrition Mechanical

Tube dislodgment, clogging

Complications of Enteral Nutrition Metabolic

Electrolyte imbalances, hyperglycemia

Complications of Enteral Nutrition Infectious

Aspiration

Complications of Enteral Nutrition Management:

Observe residuals. Watch for signs and symptoms of gastric intolerance. Do not add medications to enteral formulas.

Complications of Enteral Nutrition Management: Why do you need to aspirate the contents? What amount is normal to aspirate someone?

It is important to aspirate the contents to see if they are tolerating the feeding. When aspirating someone, upto 250mL is normal. But it also depends on the facility.

Parenteral Nutrition (PN): When is this indicated?

Oral or enteral nutrition is not possible. Absorption or function of the gastrointestinal tract is not sufficient.

Parenteral Nutrition Formulas

May be either Total Parenteral Nutrition (TPN) or Peripheral Parenteral Nutrition(PPN)

Parenteral Nutrition Formulas What does TPN require?

TPN requires a central line (save one port)

Parenteral Nutrition Formulas What must be done for each ingredient? What kind of solution is used?

Verify orders for each ingredient Refrigerated solution

Parenteral Nutrition Formulas What should not be done in this line?

Do not inject any med into this line

Parenteral Nutrition Formulas How much solution should be in this line?

2-3 L of solution in 24 hours

Parenteral Nutrition Formulas What kind of filter should be used?

Using a filter (1.2 micron particulate filter)

Parenteral Nutrition Formulas What should be inspected? Why?

Inspect solution for clarity and precipitate

Parenteral Nutrition Formulas You can't withdraw blood from the same port you are feeding, why?

You can’t withdraw blood in the same port you are feeding because it will lead to improper results and contamination can occur.

Parenteral Nutrition Formulas How are you administering TPN?

If you are administering TPN- usually by central line.

Parenteral Nutrition Formulas How are you administering PPN?

If you are administering PPN- peripheral line is smaller compared to central line.

Central Methods: Triple Lumen Catheter What must be done before starting TPN?

Confirm placement of catheter tip by x-ray before starting TPN

Central Methods: Triple Lumen Catheter What kind of catheters may be used? What cannot be done with the catheter?

Single, double, or triple lumen catheters may be used Blood can not be drawn from catheter

Central Methods: Triple Lumen Catheter What is used for long term?

TPN

Central Methods: Triple Lumen Catheter What is used for short term?

PPN- because it is a smaller vein

Peripheral Parenteral Nutrition (PPN): How is it infused?

PPN is infused into smaller peripheral vein via peripherally inserted central catheter (PICC).

Peripheral Parenteral Nutrition (PPN) How long is it used as nutritional support?

Short-term nutritional support (7 to 10 days)

Peripheral Parenteral Nutrition (PPN) How to supplement?

Supplement during transitional phases to enteral or oral nutrition

Peripheral Parenteral Nutrition (PPN) Concentrations of PPN formulas must not exceed what? Why?

Concentrations of PPN formulas must not exceed 900 mOsm/L to minimize risk of phlebitis.

Complications of Catheter & Parenteral Nutrition

Pneumothorax during insertion Air embolism during insertion Clotted catheter line Catheter displacement Catheter contamination Sepsis Hyperglycemia: supplement with insulin Fluid overload Rebound hypoglycemia

Complications of Catheter & Parenteral Nutrition Since hyperglycemia can occur, what must be done?

Hyperglycemia: supplement with insulin

Complications of Catheter & Parenteral Nutrition What is pneumothorax?

Pneumothorax- air in the chest cavity which could lead to a collapsed lung.

Complications of Catheter & Parenteral Nutrition Rebound hyperglycemia:

Rebound hyperglycemia- happens right after a person is fed. Could be minutes or hours.

Nursing Interventions What should you check insertion site for?

Check insertion site for leakage; bloody purulent drainage; a kinked catheter; skin reactions such as inflammation, redness, swelling or tenderness

Nursing Interventions What should you assess for?

Assess for signs of dehydration Obtaining initial “dry weight” and weekly weights Vital signs Intake and output Assess enteral tube and IV catheter. Assess abdominal and abdominal girth. Bowel sounds

Nursing Interventions What should you provide for the family and patient?

Provide information and emotional support to the patient and family.

Week 2 Flashcards

Exam 1