Med Surg: Nutritional Needs – Flashcards
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What is TPN
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a method of providing all the nutrients that a client will need for a 24 hour period through an IV
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What type of vein must TPN run through
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central
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What type of vein can PPN run through
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peripheral
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Why must TPN run through a central vein
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because it is a vesicant and running it through a large vein will allow it to be diluted
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Where are the central lines located
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in the trunk of the body, subclavian, internal jugular, PICC
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How is TPN administered
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on an infusion pump
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What are the goals of TPN
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improve nutritional status establish a positive nitrogen balance maintain muscle mass promote weight maintenance/ gain enhance wound healing
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Who decides what is in a TPN solution
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the entire health team based on labs, physical assesment, and underlying disease process
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Why can traditional IV fluids not be used for TPN
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does not provide sufficient calories
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How many calories are in D5W
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4 cal/g
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What are the clinical indications for using TPN
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multiplicity of problems 10% loss of pre-illness body weight NPO NPO sevan days after surgery enternal nutrition not an option hyper-catabolic situation (hyperthyroidism, severe burns) major illness (cancer)
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what is cacexia
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severve malnutrition
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what is one sign of cacexia
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temporal wasting
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What is TPN composed of
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amino acids-protein (wound healing) glucose or dextrose ( energy) fat (maintain body temp, increase caloric consumption) insulin
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Where does the glucose in TPN come from
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beet pulp becuase it has a lower glycemic index which helps reduce the risk of hyperglycemia
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What electrolytes are in TPN
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K+ (muscle function) 3.5-5.3 mEq Ca++ (bone growth and maintenance, muscle contraction, neuromuscular interaction) Mg ++ (muscle and neurological fxn) Na + (muscle contraction) Cl - and PO4 ( acid/ base balance, muscle fxn)
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What trace elements are included in TPN
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micro-nutrients zinc (wound healing, collogen strength) copper (promote tissue profusion) selenium (muscle mass) iodinw fluoride cobalt nickle iron
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Which vitamins are fat soluable
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ADEK
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which vitamins are water soluable
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B complex and C
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When is thiamine added to a TPN solution
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when there is suspected ETOH abuse or impaired liver fxn
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What type of soultion is TPN
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hyperglycemic
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What type of insulin can be added to TPN
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REGULAR
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What is the #1 way to seeif TPN solution is beneficuual
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weight assesment
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What should be assesed to determine need for TPN
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electrolyte status caloric intake protein loss (decreased skin tugor and muscle mass) - pre-albumin labs
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Nursing Dx associated with the need for TPN
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imbalanced nutrition less than body requirements r/t inadequate oral intake of nutrients AMB muscle waisting, low albumin leves, decreases levels of pre-albumin, weight loss, and poor tissue healing
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Examples of nursing goals while on TPN
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balanced nutrition gain 3lbs within a week labs within normal limits
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What are some complications that can occur with TPN
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infection hyperglycemia hypoclycemia (shaking, sweating, irritablity) fluid volume overload air embolism
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Nursing Dx for client who has infection in TPN lin
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Risk for overwhelming baterial infection
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Signs/ symptoms of infection
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fever chills swelling and erythemia at catheter site purulent drainage tachycardia tachypnea change in LOC hypotention increased WBC septic shock
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how to prevent CRBI
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strick aseptic tecnique change solution per hos. protocol change tubing q 12 hrs change dressign per hos. protocol bag and tubing should not hang longer than infusion time
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What should be done if CRBI occurs
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pull cath and send to lab for culture admin abx as ordered
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causes of hypergylcemia durring TPN therpay
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blood gluscose levels > 200mg/ dl too rapid infusion of TPN stress of illness
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Sign and symptoms of hyoerglycemia
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excessive thirst, fatigue, polyuria, restlessness, confusion, weakness, diuresis, hyperglycemic coma
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Nursing interventions to prevent hyperglycemia durring TPN
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assess BG as ordered sliding scale insulin maintain BG < 200 mg/dl
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What would put a client at risk for hypoglycemia durring TPN therapy
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TPN being abruptly discontinue toomuch insulin via TPN or sliding scale
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Signs and symptoms of hypoglycemia
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shaky, weak, diaphoretic, may be hungry, BG < 70 mg/dl
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nursing implementations for prevent hypoglycemia
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monitor BG gradually decrease TPN flow rate always use infusion pump never stop TPN abruptly infuse D10W infusion or D50 IVP restart additional IV
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Signs and symptoms of an air embolism
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resp distress, restlessness, chest pain, hypertension, weak pulse, tachycardia
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what should be done if air embolism is suspected
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place pt in trendelenburg and place on left side
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prevention of air embolism
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valsalva maneuver durring tube change prime tubing check connections
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What does CRBI stand for
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catheter related bloodstream infection
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signs and symptoms of fluid volume overload
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restlessness, resp distress, change in LOC, tachypnea, tachycardia, bounding pulse, increased BP, JVD, wet lung sounds, decreased 02 stats, excessive weight gain
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fluid overload prevention
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use pump dont play catch up
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what should be done is fluid volume overload is suspected
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don't leave pt sit bed up anticipate giving 2-4 lt o2 via cannula diruetics
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rules regarding rate of TPN
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start low, go slow 50 ml/hr if rate is not writtin in order increase gradually over 24hr period until rate is reached
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additional complications
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venous thrombus movement clot or thrombosus in cath electrolyte imbalance excessive weight gain increased lipid levels fatty liver (monitor trigycerides, glucose) refeeding syndrome
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signs of refeeding syndrome
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acute decrease in K+, Mg++, PO4 hypoglycemia
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who is at risk for refeeding syndrome
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severly malnurished pt beginning on TPN
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TPN nursing interventions
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know facility protocols maticulously care for TPN site accurate I&Os daily weights
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what is always the # intervention
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assesment
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what is tube feeding
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enteral nutrition administration of nutritionally balanced liquefied food through tube inserted into stomach, duodenum, or jejunum
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advantages of enteral feeding over TPN
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easily administered, safer, more physiologicallu effcient, less expensive
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how is tube placement varified
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x-ray ausculation of air aspiration of stomach fluids ( pH around 5)
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how often should placement be assesed
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q8hr
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what are the advantages of using a dobb-hoff
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more flexible and comfortable less mucosal damage
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indications for enteral feedings
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anorexia orofacial fractures head/ neck cancer burns nurtitional deficiencies neurological conditions phychiatric conditions chemotherapy radiation therapy
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tube feeding delivery options
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continuous infusion by pump intermmittent by gravity intermittent bolus by syringe cyclic feeding by infusion pump
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Nursing Dx with enteral feedings
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Risk for aspiration r/ t reflux
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complcations related to nasogastric and nasointestinal tubes
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can become silodge by vomiting or coughing tube can end up in trachea increases resk for aspiration can become knotted/ kinked in GI tract
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when would a gastrostomy or jejunostomy tube be used
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for long-term feedings when GI tract is intact and unobstructed
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how are gastrostomy or jejunostomy tubes placed
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surgically, radiologically or endoscopically
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what is a PEG tube
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Percutaneous Endoscopic Gastrostomy
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how is a PEG tube placed
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via percutaneous endoscopy through esophagus into stomach andthen pulled through a stab wound made in abdominal wall
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how should pt being positioned durring enteral feeding administration
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sitting or lying with HOB at 30-45 degrees HOB should remain elevated for 30 -60 minutes after intermittent delivery
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what should be done to help keep tube patent
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by administering water before/ after each feeding, drug admin, and residual checks
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when should placement be checked
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prior to intial feeding prior to irrigation prior to med admin prior to fluid admin q shift
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what should be done before begining a feeding
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aspirate gastric contents and measure amount
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when should a feeding be held and why
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if more than 150 ml is aspirated b/c it can be a sign of clinical intolerance
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what is done with residual stomach contents
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put back through tube
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what is the appropriate tempurature for formula and why
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room/ body temp prevents cramping and abdominal distension overall GI comfort
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standard volume for intermittent feedings
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200 to 500 ml
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what will help to decrease tube feeding diarrehea
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administration of "free water"
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general nursing considerations with enteral feedings
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daily weights BMI skin turgor assess bowl sounds before feedings accurate I&Os initial glucose checks label with date and time feeding was started feeding infusions older than 8 hrs should be discarded tubing changed q 24 hr
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nursing considerations with enteral feedings
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verify tube placement position pt safely correct formula aseptic technique admin feeding according to order maintain tube patency assess tube feeding residuals admin free water as ordered
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enteral complications
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aspiration vomiting diarrhea constipation dehydration
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when is a high protein formula contraindicated
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in pts with renal failure
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aspiration prevention
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elevate HOB check residuals assess lung sounds and respiratory status
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diarrhea prevention
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start feedings slow dilute initial feedings perineal care assess fluid and electrolyte status
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gerontologic considerations
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fluid and electrolyte balanaces glucose intolerance decreased ablity to handle large volumes increased risk of aspiration
