CHAPTER 5PATIENT CARE SKILLS

Assisting with Enteral Nutrition

Assisting with Enteral Nutrition

Objectives– Define the key terms in this chapter– Describe the routes for enteral nutrition– Explain the purpose of enteral nutrition– Describe how to handle formula for enteral nutrition– Explain the difference between scheduled and continuous feedings– Explain how to prevent aspiration and regurgitation– Identify the signs and symptoms of aspiration– Describe the comfort measure that relate to enteral nutrition– Explain the safety precautions involved in giving tube feedings– Identify the reasons for removing a nasogastric tube– Perform the procedures described in this chapter: giving a tube feeding,

removing a nasogastric tube.

Enteral nutrition=giving nutrients through the GI tract.

Feeding tube inserted into the stomach or small intestine.

used when food can't pass normally from the mouth into the esophagus and into the stomach

Conditions that are common

cancer of the head neck, or esophagus trauma to face, mouth, head or neck. surgery to face, mouth, head, or neck. coma dementia

Types of feeding tubesTemporary

A. nasogastric tube (NG) inserted through the nose into the stomach. performed by a nurse or doctor

B. nasointestinal tube (NI) inserted through the nose into the duodenum or

juejunum of the small intestine doctor or RN performs procedure

Types of tube feedingsPermanent

A. gastrostomy• opening into the stomach created surgically

B. jejunostomy• inserted into the middle part of the small intestine• created surgically

C. percutaneous endoscopic gastrostomy (PEG ) tube• inserted with an endoscope through the mouth and esophagus

into the stomach.• incision is made through the skin and into the stomach, tube is

inserted through the incision.

Methods of Administering

Syringe– Uses a 60 ml syringe – Flow rate is controlled by gravity

Feeding bag– Formula is poured into a bag hung from IV pole– Flow rate is adjusted by the height of the bag on the pole

Feeding pump– Formula poured into a bag and tubing is threaded through a

machine– Rate is controlled by the pump

FeedingsScheduled

May be Scheduled or continuous feedings ordered by the doctor which way to be given

FeedingsBolus intermittent feeding

receives a large amount of formula over a relatively short period of time.

FeedingsContinuous

require feeding pumps can be nasointestinal or jejunostomy tube feedings formula is to be kept at room temperature: cold can

cause cramping formula is added every 3 to 4 hours never add new formula to formula in the bag d/t

contaminated never hang more than 4 hours to prevent the

growth of microorganisms

FeedingsCyclic feeding

receives small amounts of formula constantly for 8 to 12 hours; then the person is disconnected from the feeding pump.

Feedings scheduled

usually given four times a day given with a syringe or feeding bag approximately 400 ml over 20 minutes amount and rate like a regular meal.

Children and ElderlyChildren

NG, G tube and PEG tube feedings more common usually scheduled not continuous position for feeding would be in your lap to allow for comfort of

the child elevate the head and chest position on right side or Fowler’s position for 1 hour (usually

directed by RN) if able amount of formula and position for feeding directed by RN infants get pacifiers to suck on during the feeding to allow

normal sucking reflex, comfort and reduce crying note cramping, vomiting, discomfort

Children and ElderlyElderly

increased risk of regurgitation d/t slowing of digestion and stomach emptying

less formula and longer feeding time than other adults

May be unable to stay on side or back for longer than 1 hour

Formulas

Many different types but common factors in each Most contain protein, carbohydrates, fat,

vitamins, and minerals. Commercially prepared or prepared by dietary

department in house Can provide an environment for the growth of

microorganisms. Must not contaminate when handling

Preventing contamination of formulas

Wear gloves when preparing or handling formula replace soiled gloves as necessary Do not use dented or damaged cans. Check the expiration date on commercial formulas. Check the date on formulas prepared by the dietary department and

Discard if >24 hours Wash cans or bottles before opening them. Label cans or bottles with the time and date opened. Refrigerate open cans or prepared formula Clear the tube before and after the feeding using 30-50 cc of water

or other fluid per facility policy Counted as part of the pts intake

Complications Aspiration

a major complication of NG and NI tubes Defined as breathing of fluid or an object into the lungs placement can cause the tube to slip into the respiratory

tract. must be determined by an x-ray to assure that tube is in the

stomach or SI may move out of place with coughing, sneezing, vomiting,

suctioning, and poor positioning. ***RN checks for placement before every scheduled tube

feeding, continuous every 4 to 8 hours by aspirating GI secretions

General care measures

Provide oral care

General care measures

Monitor bowel movements

General care measures

Prevent complications– Aspiration– HAI– Dehydration– Dumping syndrome

Aspiration-signs and symptoms

nausea discomfort during the feeding vomiting diarrhea distended abdomen coughing complaint of indigestion or heart burn redness, swelling, drainage, odor, or pain at site of ostomy elevated temp respiratory distress increased pulse complaints of flatulence

ComplicationsRegurgitation

backward flow of food from the stomach into the mouth

can occur with NG, G, PEG tubes less often with NI, J tube common causes

1. delayed stomach emptying

2. overfeeding prevention

-sitting or semi-Fowler’s position for feeding and remain for 1 hour after.

*******never left side lying position*******

Comfort measures

usually NPO, causes dryness of mouth, lips, sore throat

may be allowed hard candy or gum, check care plan

frequent oral hygiene lubricant for the lips mouth rinses Nose and nostrils are cleaned q 4 to 8 hours secure NG tube with tape to nose and gown to

relieve pressure on nose

Giving a tube feeding You may assist the RN and then complete on own as AP and PCT

guidelines to follow before giving a tube feeding must be allowed by the state be in job description by educated and trained to perform know how to use the equipment at the facility review the procedure with the RN RN available to answer questions RN checks tube placement***patient may have IV infusions, drainage tubes, and

breathing tube as well as GI tube. MUST KNOW THE DIFFERENCE****

Report to the Nurse Immediately

Coughing or wheezing Diarrhea or constipationDifficulty breathing FeverLow reading on pulse oximeter

Abdominal pain or bloatingCyanosis Dry mucus membranesNausea or vomitingDecreased or very concentrated urine

Total Parenteral NutritionHow TPN Differs From Enteral Nutrition

TPN bypasses the digestive tract and delivers the nourishment directly into the bloodstream and is not digested.TPN is administered through a central line into one of the two large veins that empty directly into the heart.

TPN is a solution that contains nutrients in their smallest form.Patients who receive TPN are very ill, injured, or may be recovering from surgery, especially gastrointestinal, and may not be able to tolerate food in the digestive tract.

Removing a nasogastric tube

removed when the person can eat and swallow. must be free of nausea and vomiting MD orders the removal of the tube check job description and state regulations Use Standard Precautions and The Bloodborne

Pathogen Standard guidelines report observations

any bleeding pt tolerance of procedure pain or discomfort during or after procedure

Bellwork

1. List two ways that a Patient Care Technician can prevent contamination of enteral nutrition formulas (1 pts)

2. Identify the following tubes by their placement and insertion site(2 pts)

nasogastric tubegastrostomy tubejejunostomy tubePEG tube

3. Define aspiration and give a common cause for its occurrence(1 pts)4. Explain the difference between continuous feeding and

scheduled feeding(1 pts)

Skill #1

- Giving a tube feeding

-see procedure in the chapter

Skill #2

-Remove a nasogastric tube

-see procedure in the chapter

SKIN PUNCTURES

= penetration of the capillary bed in the dermis of the skin with a lancet or other sharp device to collect a blood specimen

=especially important in pediatrics =fingers in adults and children older than 2 =heels of infants

Taking a blood glucose

Skill practice

Equipment Lancet microcollection tube/container microhematocrit tube

Site selection criteria-skin puncture– warm, pink, or normal color– free of scars, cuts, bruises, or rashes– no cyanosis– no edema

Infants– heel recommended site for infants less than 1 year– precautions: DO NOT PUNCTURE

deeper than 2.o mm through previous puncture sites the area between the imaginary boundaries the posterior curvature of the heel in the arch causing injury to nerve, tendons, and cartilage areas of the foot other than the heel

older children and adults– palmar surface on the distal segment of finger– usually nondominant hand– fleshy central portion, slightly to side and tip– perpendicular to whorls(grooves in the fingerprint)

– DO NOT PUNCTURE: Side or tip of the finger Parallel to grooves of the fingerprint

– causes blood to run down the finger rather than form a round drop

The index finger– more callused and harder to poke– used more often and cause more pain

Fifth or little finger– thinnest tissue– Fingers of infants and very young children

Check that the dressing over the central line insertion site is clean and dryNotify the nurse if the dressing becomes wet, soiled, or looseMonitor the patient’s blood glucose levels

Nursing Assistant’s Role

Monitoring Glucose Levels

The TPN solution is very concentrated and contains a great deal of glucoseIt is delivered directly into the bloodstream, causing the body to have difficulty monitoring and regulating the blood glucose levelGlucose levels should be monitored every 6 hoursPatients taken off TPN should continue to have their glucose levels checked for hypoglycemia

PERFORM A SKIN PUNCTURE

Key TermsGenitourinary Skills

1. Ostomy2. loop stoma3. double barrel stoma4. end stoma5. enterostomal therapy6. ileostomy7. effluent8. colostomy9. irrigation

10. stenosis11. perforation12. prolapse13. diverticulitis14. flatus15. herniation16. necrotic17. peristomal

Ostomy Care

Ostomy= a surgically created opening that serves as an exit site for fecal matter.

Colostomy=an opening created anywhere along the large intestine or colon

Ileostomy=an opening into the ileum or terminal portion of the small intestine

Reasons for using a stoma

Genetic defect Inadequate blood flow

– Removal of necrotic section Traumatic adnominal injury Disease process

– Cancer– Diverticulitis– Polyposis– Crohn’s disease– Ischemic bowel– Ulcerative colitis

TYPES OF STOMAS

Loop stoma– Loop of intestine is brought to the abdominal

surface– Usually temporary, closed in 2-3 months– Bowel function returns to normal

TYPES OF STOMAS

Double barrel stoma– A portion of the bowel is removed and both ends

are brought to the surface to form two stomas

Proximal=functioning part Distal=non-functioning part

– May be permanent or rejoined when healed

TYPES OF STOMAS

End stoma– Created when disease or pathology is present– Affected portion and all parts below it are

removed to prevent further spread– Stoma will be proximal to affected area– Permanent or temporary

Anatomy reviewSmall intestine

-primary functions1.digestion

2. some absorption-26 ft. long and one inch in diameter-parts

– duodenum– jejunum– ileum

-effluent (output or drainage from a stoma) is semi-liquid and caustic to the skin.

Anatomy reviewLarge intestine

-two primary functions absorption of water transportation and storage of fecal matter

-6 to 8 ft long and 2 ½ inches in diameter-parts

– ascending colon– transverse colon– descending colon– sigmoid colon

-effluent ranges from liquid to semi-formed to formed depending on the location

-not as corrosive as to the skin

Choosing a pouch system

DETERMINING FACTORS:1. Type of effluent

– liquid of fairly constant would take a drainable pouch

– formed would take a security pouch with a closed end

2. Presence of disabilities- a patient with limited manual dexterity would use a one-piece system- a two-piece system for those who are mobile and able to reach the ostomy site without difficulty

Choosing a pouch system (con’t)

3.Personal preference

-pt must feel comfortable and capable

4. Physiology

-size and shape of the stoma

-size and contour of the abdomen

-peristomal skin condition-physical activities/ manual dexterity

-opening of the skin barrier for the stoma will continue for six to eight weeks

Changing a pouch

*See procedure sheet*

Equipment neededwritten instructions for the patientclean towelwashclothsoap and watermeasuring guideflangepouchpouch clamppenscissorsprotective skin barrier pastedisposable bag

-enterostomal therapy occurs after the stoma is placed during surgery (therapy to help the patient with care of the stoma and peristomal area)

-postoperatively the enterostomal nurse (ET nurse) is responsible for the preparation and application of the post-op pouch and the following responsibilities:

– remeasure the stoma each time the pouch is changed– Check the pouch for leakage– Any complaints of itching or burning should be assumed as

leakage– Empty the pouch when it is one third full of stool or flatus

(air in the intestine that causes gas) high output post-op, then 600 to 1000cc for 2 months

Monitor the stoma – -normal=red, moist, and shiny, with skin intact– Document observations in the chart

-amount of effluent -appearance of stoma -appearance of the peristomal area

SKILL #3

Perform change a pouch

BELLWORK

Explain the difference between a colostomy and an ileostomy’ (1 pt)

How is the type of pouch system determined. (2 pts)

Define effluent. (1 pt)

Determine the difference in the effluent from a colostomy and an ileostomy (1 pt)

Patient Education

-teach basic anatomy and physiology, self care techniques*how to empty the pouch*how to measure the stoma*how to cut the opening in the skin barrier*how to apply the pouch and clamp

-teach from simple to complex. -irrigation (cleansing the colon by flushing with water)

may be taught but will depend on the patient and bowel function

-most require immediate attention skin breakdown blockage obstruction continuous stomal bleeding prolapse (a falling or dropping down the intestine) herniation (when the intestine protrudes into the abdomen) stenosis (constriction or narrowing of the opening) perforation (a hole made through a part) dehydration

Diet

a dietician is needed for educating the patient post-op.

foods given post-op depend on the ostomy site

advise to avoid foods that cause excessive odor, flatus, constipation, or diarrhea

new foods introduced one at a time, until effects are known

celery Chinese food nuts coconut wild rice popcorn whole grains coleslaw seeds/kernels raw veggies raw fruits

fish eggs asparagus onions garlic beans peas cabbage turnips

Gas Forming Foods

cabbage beans Mexican Dairy Mushrooms Beer Carbonated drinks Pickles Eggs Onion Broccoli Corn Yeast Spinach

green beans

broccoli

spinach

raw fruit

fried foods

highly seasoned foods

Foods that Change color of stool

beets

tomatoes

strawberries

spaghetti sauce

Control diarrheabananas

applesauce

boiled rice

boiled milk

tapioca

yogurt

buttermilk

peanut butter

Psychological complications

depression withdraw from activities decreased self-esteem change of self image

QUESTIONS ????????????