"Tube Feeding"

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Assessment prior to oral supplement/tube feeding
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Clinical signs of malnutrition or dehydration Food allergies Lactose intolerance Presence of bowel sounds Delayed gastric emptying, abdominal distention, diarrhea, or constipation.
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Enteral Feedings(tube feedings)
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May be needed with: head and neck tumors, esophageal stricture coma, anorexia of chronic illness, anorexia nervosa, hyperemesis gravidarum, swallowing problems.
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Enteral feedings are used to..
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Supplement or replace oral feedings. Standard formula: 1 Kcal per ml. Give bolus, intermittently, or continuously
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Bolus
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Syringe used to deliver the formula rapidly
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Intermittent Feedings
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300-500 ml several times daily over at least 30 minutes. Feedings typically given every 2-4 hours. For stable long term patients. Tolerated better if given by slow drip rather than rapid infusion.
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Problems with tube feedings
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Flow may be too rapid or volume too large. Stop the feeding if the client experiences abdominal discomfort, diarrhea/nausea, tachycardia.
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Continuous Feedings
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Administered over a 24 hour period per infusion pump (known as a kangaroo pump). Note: pump essential when feedings are administered in the small bowel.
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Cyclic Feedings
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Are continuous feedings administered in less than 24 hours (12-16 hours).
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Continuous NG and gastrostomy feedings
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Keep gastric pH lower than usual which causes increased bacterial and fungal growth. With aspiration, this causes an increased risk of pneumonia. Reduce risk of dumping syndrome. Cause less diarrhea and more adequate intake than intermittent feeding in cases of tube feeding due to stress (EX: burns)
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Types of tube feedings
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Polymeric formula Elemental or oligomeric
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Polymeric formula
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Usual formula. Has protein, CHO, and fat. Fiber is found in some to help control bowel function. Most commercially prepared formula are lactose free because lactose intolerance is common among older adults and individuals with malabsorption.
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Elemental or Oligomeric
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Pre digested. Consists of protein hydrolystates, peptides, and free amino acids(broken down from original protein). Disease or condition specific formulas (EX: AIDS, diabetes, hepatic encephalopathy, pulmonary disease, renal failure, wound healing and critical illness)
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Tube feedings(formula)
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Standard formula- 1 Kcal per ml. Calorie dense formula- 1.5 to 2.0 kilocalories/ml for those needing fluid restriction. Monitor hydration status and provide free water as needed. May be isotonic or hypertonic.
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Tube feedings
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Tube feedings are initiated at a low rate and gradually increased to prevent diarrhea. If diarrhea occurs, MD may order 1/2 or 1/4 strength formula. Nurse must dilute the feeding by adding water. 1/2 strength= 1 can formula/1 can H20 1/4 strength= 1 can formula/ 3 cans H20
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Enteral tubes
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Nasogastric Nasogastric & Nasointestinal G-tube PEG tube
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Nasogastric tubes
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(Levin or Salem sump- not used for feeding- used to decompress the stomach). Size- large bore (12 fr)
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Nasogastric & Nasointestinal tubes
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(Called feeding tube or dobbhoff). small bore (8, 10, 12 fr)
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G-tube
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Gastric tube: inserted surgically into stomach
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PEG tube
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(Percutaneous endoscopic gastric tube). Placed surgically via & tunneled under skin so 100% sure is in right place.
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NG & feeding tube types and uses
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Short term: Nasogastric (NG)- easily inserted but easily dislodged (causes aspiration). Nasoduodenal (ND) Nasojejunal (NJ) Long term: Esophagostomy Gastrostomy- must have patent esophagus. Secretions irritate skin. Jejunostomy
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Feeding tube insertion
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-select appropriately sized tube. To determine the length of tube: measure from nose to top of ear to top of xyphiod process. -explain procedure to the patient. -lubricate tube with H20 soluble lubricant(KY jelly). -have client sit upright -have client tuck chin and neck. Insert into nares quickly and keep inserting. -encourage swallowing while tube is advanced. -after tube is in, tape tube onto nose. -if client is coughing or has difficulty breathing, remove tube immediately!!!
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Why must an abdominal x-ray be done immediately?
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To see correct placement or tube in the stomach and not lungs
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Confirm tube placement
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Check placement by aspirating gastric contents and placing on litmus paper: pH <5- in stomach or small Bowel Greater than 5.5- likely placement in lungs or large bowel
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The nurse must…
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Assess tube placement and residual at each initial assessment & Q 4 hours
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What equipment is used?
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60 ml catheter tip syringe Emesis basin or empty cup Clean gloves Cup H20 Litmus paper
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All clients with NG tubes/G tubes/ PEG tubes/ or feeding tubes must always be…
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In fowlers position or at least 30 degrees elevation. The higher the better to prevent aspiration
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Assessment
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Explain procedure Wash hands Provide privacy Check placement by aspirating gastric contents and placing on litmus paper
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Administering the feeding
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-assess placement and residual. -if 100 ml or more, HOLD tube feeding for 1 hour, then reassess in 1 hour. If still more than 100, call doctor because the stomach is not emptying properly and can become distended and cause aspiration or vomiting. -check expiration date. -avoid cold feedings -clamp tubing and add formula -prime tubing and adjust drip if not on pump. Attach to tube. -flush tube with tap H20 according to policy or MD order.
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Administering medication per NG
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-assess placement and residual -NEVER ADD MED TO FORMULA -check to see if med may be crushed -crush meds and mix into H20 -aspirate med into syringe, push into tube -flush with at least 60-100 cc H20 -clamp tube X 30 minutes
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Why is mouth care essential?
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Because of constant gastric stimulation causing increased saliva. Rinse mouth with water or mouth wash and brush teeth
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What are complications of tube feedings?
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Diarrhea RT to high carbs and increased GI motility. Pulmonary aspiration. Constipation (rare), due to decreased H20 if client isn’t getting free water on a daily basis.
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Nursing actions
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Assess: glucose, Na, K, Ca, Phos, Mg. BUN and creatinine CBC Serum triglycerides Serum albumin, transferrin, and pre albumin.
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What Nursing actions do you use with an NG?
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Clean nose and tube with water and Cotton applicator. Check nose for irritation/erosion. Clean made with cotton swab.
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Reasons for placement
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-Gut decompression: prevent N/V post-op -To deliver nutrients -Empty stomach contents, toxins or poison
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How to verify tube placement
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x-ray
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Check tube placement
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ALWAYS ___________ before use, and as often as necessary during use
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Stomach pH
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less than 4
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Lung pH
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greater than 6
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Intestine pH
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7-8
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What to do if unable to aspirate
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Reposition client onto left side
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NG tube Complications
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-Fluid and electrolyte imbalance -Mucus membrane erosion -Sore throat
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Fluid and electrolyte imbalance
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-Gastric decompression, metabolic alkalosis -Intestinal decompression, metabolic acidosis -Dehydration
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Tube Feeding Complications
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-Aspiration/vomiting -Dehydration -Diarrhea
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Tube Feeding Documentation
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-type/size of tube -tube placement -amount of residual obtained -type of solution & volume of feedings -how client tolerates -delivery system tubing changes
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Monitoring Tube feeding
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-VS q4h -Blood sugar q6h -labs: everyday/everyweek -daily weights
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Tube feeding NRSG dx
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-Altered nutrition -Altered comfort (N/V) -Fluid volume imbalance -Risk for altered metabolism -Risk for injury: aspiration
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Define enteral nutrition
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Delivery of nutrients to the GI tract via a tube i. orally via esophagus ii. tube feeding
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Uses of oral supplement to help meet a patient’s nutrient needs
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i. Give these when a person is not able to eat enough food and get enough nutrients through food alone. ii. Between meals iii. Added to food (mashed potatoes, oat bran, cereals) iv. Added into liquids for medication pass v. Enhances otherwise poor intake
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When to Tube Feed?
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i. Inadequate oral intake: can’t be able to meet their own needs orally ii. All oral diet methods exhausted (Supplements, modifications) iii. Functioning GI iv. Protein Energy Malnutrition by mouth intake for more than 5 days 1. Already malnourished by mouth 2. Have not been eating enough for more than 5 days v. Meeting less than ½ of nutrient needs my mouth for 7-10 days vi. Severe Dysphagia vii. Major Burns-> when their calorie and protein needs are very high viii. Cancer ix. Some GI complications and resections (helps the gut heal after surgery)
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Benefits of TF compared to parenteral nutrition (vein)
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i. Maintains gut integrity ii. Reduced infection rate iii. Safer iv. Cheaper v. Most physiologic route (most natural)
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Contraindications (When not to tube feed) of Tube Feeding
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-GI obstruction -Shock -Client/legal guardian does not want TF -Prognosis doesn’t warrant aggressive support
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List the access (placement) sites of a tube feeding
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-Orogastric -Nasoenteric (NG, ND, NJ) -Enterostomy (gastrostomy, Jejunostomy)
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What is orogastric?
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mouth to stomach
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Considerations for orogastric of when to use
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-Used in preemies and may be used in adults with trauma to sinus area -Not very popular -No talking
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What are each nasoenteric?
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nose to… -stomach NG (nasogastric) -duodenum ND (nasoduodenal) -jejunum NJ (nasojejunal)
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Define enterostomy
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make a new opening for feeding
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Considerations for when to do enterostomy for feeding
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-when nasoenteric placement is unavailable -TF is required for more than 3-4 weeks (irritation) -Severe head and neck trauma
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Forms of enterostomy
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-Gastrostomy (G-tube, PEG, gastric tube) -Jejunostomy (j-tube, PEJ)
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Gastrostomy (G-tube, PEG, gastric tube) explain
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-Percutaneous endoscopic gastric tube -Placed outside in via surgery under the skin
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Advantages to Nasogastric or G-tube
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o Closer to natural eating o Nothing is bypassed o Food gets digest o Stretch receptors, hunger o Greater absorption of nutrients o Still using pyloric sphincter -Controlled rate of emptying -Less risk of dumping o Normal digestion maintained o There are risks (page 4 in notes)
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Advantages to feeding to (ND, NJ, J-tube)
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-Decreased risk of aspiration -Intestinal motility returns sooner than stomach
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Disadvantages to feeding to ND, NJ, J-tube
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Digestion is less complete -as it bypasses the pyloric sphincter (no controlled rate of emptying)
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Verifying tube placement
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-Auscultation -Check residuals or aspirates -check pH of residules -X-ray
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What is the Auscultation method
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Blow air into tube and listen
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Complications that might happen when a tube is misplaced
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-food goes into lungs. -puncturing lungs or other body organs
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Checking for residuals or aspirates method
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o Suck out stomach contents to verify we are in the stomach and see how fast they are digesting o Off white, green, tan-gastric o Yellow, green, brown-intestinal o White, yellow, clear-respiratory o Should be used secondary, too much overlap
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Checking for pH of residuals method
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But pH can be very close to each other as well
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X-Ray method
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-Gold standard method -Safest for patiens
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Considerations for formula selection
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-Calorie dense formula -Osmolarity of formula -CHO (diabetic) -Lipid (lower for heart disease) -Protein amount -More hydrolyzed, more elemental
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Tube feeding compositions
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-standard -concentrated -high nitrogen
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standard tube feeding composition
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o Lactose free o 1 kcal/mL o Dumping syndrome o Hard to digest
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concentrated tube feeding composition
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o To give more calories w/ less volume o 1.3 – 2 kca/mL o ***Use this for renal disease or someone on fluid restriction
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high nitrogen tube feeding compositin
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o Many wounds, lots of surgery o Disease specific formulas -Critical Care +Crucial has omega 3 and arginine ( turns to nitrogen in the body) supplemented for immune system and extra antioxidants -Pulmocare •Respiratory •Very low CHO •Low CHO for respiratory disorders •Decease CO2 production
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Classifications of formulas
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-polymeric -partially-hydrolyzed -elemental -modular
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Polymeric formula: describe and what situations to be used?
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-intact CHO, Pro, Fat -for normal digestive capacity -meal replacement (ensure/boost) or tube feeding formula
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partially-hydrolyzed formula: describe and what situations to be used?
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-Semi elemental -for patients with compromised digestion and absorption (small intestine) -mono and di saccharides -MCT, easier to metabolize -medium and short peptides =more expensive =hyperosmolar (due to particle size) =small particle size can affect how the patient responds to this feeding
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elemental formula: describe and what situation to be used?
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Predigested -free from amino acids -low in fat -high osmolality =readily absorbed w/ minimal digestive work
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modular formula: describe and what situation to be used?
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-single macronutrient (Just CHO/Pro/Fat) -Use this when other supplements don’t fulfill patient needs -This by itself is NOT ok
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Continuous feeding pros
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-great for critically ill and malnourished patient -minimized risk of high residuals/aspiration *because you feed less at one time
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continuous feeding cons
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restriction of moving
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what feeding is only used for jejunal?
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continuous because it can’t tolerate a high volume
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cycled feeding info
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-continuous infusion at a higher rate for 8-16 hours -a night time feeding -100 cc/hr x 12 hrs -more flexible for patient -less time to feed means an increased formula need to be given
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cycled feeding pros
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-common for non-critically ill, rahab home patient -greater freedom, can move around w/o pump or IV -benefit for transitional feedings *oral during the day; TF @ night
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cycled feeding cons
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-may require increase protein/kcal formula -possible of GI intolerance due to increased volume
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intermittent fusion info
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-divided feedings administered usually 3-6 x a day -each feeding 30 – 60 minutes -200 cc every 4 hr run over 30 minutes (higher volume) *can this person’s GI system and tube end point handle this volume? -similar to cycled feedings although GI intolerance risks are even more possible *aspiration due to volume *N/V due to volume *pain from over feeding *diarrhea due to dumping syndrome
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intermittent infusion Pro
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more physicologicaly acceptable b/c we didn’t eat all day long and -person can move
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Bolus feeding info
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-10-15 minutes administration up to 500 mL by syringe – 200 cc every (q) 4 hours or greater … 500 ML) – Very inexpensive *No pump for administration =Only appropriate for gastric (stomach) feedings *b/c this volume/time is so high
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What’s the only place a bolus feed can be sent to?
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Stomach
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Bolus feeding pro
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more physicologicaly acceptable b/c we didn’t eat all day long and -person can move more
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Open system
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-Product is decanted into a feeding bag -Allows modular to be added (add more protein, or fat b/c you are mixing it) -Increased food service and nursing time -Shortens hang time *Time/Temperature abuse, how long can formula sit before bacterial forms -Increased risk of contamination b/c humans con introduce bacteria during preparation -Hang time * 8 hours for decanted formula * 4 hours for modulated, formula mixtures -b/c added ingredients change environment for bacteria growth -Rinsing * Bag and tube need to be rinsed each time formula is replenished =Contaminated feedings are associated with patient infection and mortality
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Closed system
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Containers are sterile until spiked and hung No flexibility in formula additives (no mixing) Less nursing time-can be hung longer Less risk of contamination Increased safe hang time (more shelf stable) More expensive Hang time o 24-48 hours depending on particular formula o Y port can be used to deliver additional fluid and modular (more protein or fat) May result in less water
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12. Know how to estimate water needs for a TF (non-fluid restricted) patient, based on either their weight and/or calorie recommendation.
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1mL/cal 30mL/kg
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13. Discuss the initiation recommendations for TF. How do they differ based on the osmolality of the formula? Isotonic formula….
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-10-40 mL/hr then -advance 10-20 mL every 8-12 hours to goal rate
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13. Discuss the initiation recommendations for TF. How do they differ based on the osmolality of the formula? hypertonic formula…..
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-starts 10-40 mL/hr then -advance more gradually as tolerated to goal -this might start out diluted
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Aspiration, safety issue w/ TB. What may help solve this problem?
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o Above pyloric sphincter w/ poor LES o Verify tube is placed correctly, not close to LES o Head above bed more than 30 degrees o Check residuals-Gastric residuals-stomach contents Shows the rate the stomach is empting o If there is more than 150 cc in the stomach, hold tube feeding Residuals are given back to patient o And or Slow down rate of TF Motility drugs to increase gastric motility Post-pyloric placement instead
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bacterial contamination, safety issue w/ TB. What may help solve this problem?
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o Especially in open system o Aseptic technique to make and hang TF Wear gloves, wash hands, sanitize food lid o Temperature control-refrigerate, seal, labeled, dated o Cross contamination-clean workspace, new gloves oTube/Bag changes-changed and rinsed as directed 24 hours or up to 72 hours but not longer
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Lack of tube patency (opening-no clog),safety issue w/ TB. What may help solve this problem?
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o Use right size of tub (French) o Irrigate tube w/ 30 – 50 mL warm water q 4 hours (continuous feeds) o Before and after every bolus o Before and after meds are administered o After stopping and before restarting o Medication should be in elixir (liquid) form if possible o Enzymes -pancreas or papain (pineapple), coke -Use these to digest a clog in tube
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Diarrhea, safety issue w/ TB. What may help solve this problem?
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-volume overload -hypertonic formula -malabsorption *swap to easier digestible formula -contamination
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N/V, safety issue w/ TB. What may help solve this problem?
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-high infusion rate (increased volume) -delayed gastric emptying (motility drug or move tube) -intolerance to formula
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constipation, safety issue w/ TB. What may help solve this problem?
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o Dehydration o Low fiber May not be getting enough formula to meet fiber needs o Decreased motility o GI obstruction
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TERMINOLOGY
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duodenum
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the first or proximal portion of the SI extending from the pylorus of the stomach to the jejunum
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INSERTING FEEDING TUBES
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enteral nutrition
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-helps meet the calorie and protein requirements of patients who cannot consume an adequate amount of food
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before inserting an NG tube check the patient for
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nasal problems such as nosebleeds, nasal polyps, chronic sinus infection, oral/facial surgery or past hx of aspiration or anticoagulant therapy =contraindications
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assess the patients
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-nares, have them plug one nare at a time and assess patency -test the gag reflex to eval ability to swallow -asucultate patients lung and abdominal sounds
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measure NG tube how?
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from tip of nose to ear lobe to xiphoid process -add 20-30 cm if inserting to duodenum or jejunum
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after tube placement…
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-check the pH along with the color and consistency of fluid -pH is around 1-4 if pt has fasted for at least 4 hours .. stomach contents is grassy green, off white or tan with the consistency of water -intestinal fluid is ph higher than 6 and will appear light to golden yellow or brownish green with a syrup consistency DT prescience of bile -respiratory fluid is clear with a pH above 7 -check x ray for tube placement prior to tube feeding
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if unable to obtain fluid when aspirating,
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turn the patient from side to side *important to note the color and constancy of the fluid
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residual from a tube feeding is
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-10-450 ml from stomach -0-10 ml from intestinally placed
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ADMINISTERING ENTERAL TUBE FEEDING
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4 types of enteral tube formula
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-polymeric -modular -elemental -specialty
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polymeric=
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delivers 1-2kcal/ ml and require that patients can absorb whole nutrients
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modular formulas=
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contains single macronutrients (protein, glucose, polymer lipids) and not nutritionally complete -deliver 3.8-4.0 kcal/ml
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elemental formulas=
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predigested nutrients, making it easier for a partially dysfunctional GI tract to absorb them -provide 1-3kcal/ ml
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specialty formulas=
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-1-2 kcal/ml -designed to meet specific nutritional needs RT illness such as liver failure, pulmonary disease, DM , HIV
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small bore feeding tubes require a _____syringe to prevent the tubing from collapsing
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50-60 ml
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prepare formula by
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-having it at room temp -check integrity -check exp date -elevate HOB 30 degrees or higher
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general amounts of flush solution used=
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6 French 1.5 to 5 mL water 8 French 5 to 10 mL water 10 French 10 to 20 mL water >12 French 30 mL water
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MANAGING FEEDING TUBES
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what is the gold standard way of detecting tube placement
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radiography..xray
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what are the most common complications of enteral tube feedings?
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-displacement, aspiration and diarrhea -formulas that contain fiber may decrease the incidence of diarrhea
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nursing measures to prevent aspiration include…
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tube placement check gastric residual assess bowel function to confirm peristalsis elevate HOB 30 degrees or higher and at least 1 hour after feeding monitor fluid and electrolyte balance
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check G tube and J tubes ..
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at least every 8 hours for signs of infection, pressure from the tube and drainage of gastric secretion
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REMOVING TUBE
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-flush with 1.5-30 ml of air, depending on the age and size of the patient to clear formula from tubing
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DOCUMENTATION
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insering a NG or NI tube
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date and time of insertion type and size of tube placed number of insertion attempts patient’s tolerance of the procedure length of tube inserted as noted by the external marking on the tube at the naris anchoring device used confirmation of the tube’s position by x-ray appearance of the aspirate (color and consistency) pH value (or other confirmatory test used) name of the person inserting the enteral feeding tube
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managing NG or NI tube
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date and time of assessment tube length noted at the exit site residual volumes appearance of the aspirate pH readings flushes administered (solution and amount) exit skin integrity and site care assessment of the gastrointestinal and respiratory tracts name of the person conducting the assessment
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managing G tube or J tube
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date and time of assessment residual volumes appearance of the aspirate tube length noted at the exit site pH readings flushes administered (solution and amount) exit skin integrity and site care assessment of the gastrointestinal and respiratory tract name of the person conducting the assessment
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administering enteral feedings via NG or NI tube
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date and time of initiation of enteral feeding position of the patient during feeding tube length noted at the exit site appearance of the aspirate pH readings flushes administered residual volumes (with discarded residuals documented under output) type of formula, rate, route, amount administered method of administration (intermittent/continuous; syringe/infusion pump) patient’s tolerance of feeding blood glucose results assessments of the gastrointestinal and respiratory tract name of the person verifying tube placement and administering the enteral feeding
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administering enteral feedings via g tube or j tube
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date and time of initiation of enteral feeding assessment of gastrostomy/jejunostomy site position of the patient during feeding verification of tube placement (appearance of aspirate, pH readings) residual volumes (with discarded residuals documented under output) flushes administered type of formula, rate, route, amount method of administration (intermittent/continuous; syringe/infusion pump) patient’s tolerance of feeding
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DC a NG or NI tube
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date and time of procedure patient’s tolerance of the procedure integrity and length of tubing retrieved name of the person moving the tube
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1
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Gather equipment. Check amount,concentration,type, and frequency of tube feeding in the patient’s medical record. Check expiration date of formula.
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2
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Perform hand hygiene and put on PPE if indicated.
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3
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Identify the patient.
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4
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Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed.
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5
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Assemble equipment over bed table with in reach.
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6
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Close the patient’s bedside curtain or door. Raise the bed to a comfortable working position,usually elbow height of the caregiver. Perform key abdominal assessments.
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7
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Position the patient with the head of the bed elevated at least 30 to 45° or is near normal position for eating as possible.
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8
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Put on gloves. Unpin the tube from the patients gown. Verify the position of the marking on the tube at the nostril. Measure the length of the exposed tube and compare with the documented length.
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9
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Attach a syringe to the end of the tube and aspirate a small amount of stomach contents.
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10
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Check the pH
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11
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Visualize aspirated contents checking for color and consistency
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12
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If it is not possible to aspirate contents, assessments to check placement are inconclusive, the exposed tube length has changed, or there are any other indications that the tube is not in place, check placement by x-ray
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13
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After multiple steps have been taken to ensure that the feeding tube is located in the stomach or small intestine: > aspirate all gastric contents with the syringe and measure to check for gastric residual > return the residual based on facility policy >Proceed with feeding if amount of residual does not exceed agency policy where the limit indicated in the medical record
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14
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Flush tube with 30 mL of water for irrigation. Disconnect syringe from tubing and cap end of tubing while preparing the formula feeding equipment. Remove gloves.
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15
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Put on gloves before preparing, assembling, and handling any part of the feeding system.
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16
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Administer feeding: feeding bag, large syringe or enteral feeding pump
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17
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Observe the patient’s response during and after tube feeding and assess the abdomen at least once per shift.
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18
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Have the patient remain in the upright position for at least one hour after feeding
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19
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Remove equipment and return the patient to a position of comfort. Remove gloves. Raise side rail and lower the bed.
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20
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Put on gloves. Wash and clean equipment or replace according to agency policy. Remove gloves.
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21
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Remove additional PPE if used. Perform hand hygiene.
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Feeding bag
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Label the bag and/or tubing with date and time. Hang the bag on an IV pole and adjust to about 12 inches above the stomach. Clamp the tubing. Check the expiration date of the formula. Cleanse the top of the feeding container with the disinfected before opening it. Pour the formula into the feeding bag and allow the solution to run through the tubing. Close the clamp. Attach the feeding set up to the feeding tube, open the clamp and regulate the drip according to the medical order, or allow the feed to run in over 30 minutes. And 30 to 60 mL of water for irrigation to the feeding bag when the feeding is almost completed and allow it to run through the tube. Clamp the tubing immediately after water has been installed. Disconnect the feeding set up from the feeding tube. Clamp the tube and cover the end with the cap.
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Large syringe
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Remove the plunger from a 30 or 60 mL syringe. Attach a syringe to the feeding tube, pour a pre-measured amount of tube feeding formula into the syringe, open the clamp, and allow the food to enter the tube. Regulate the rate, fast or slow, by height of the syringe. Do not push formula with syringe plunger. Add 30 to 60 mL of water for irrigation to the syringe when feeding is almost completed, and allow it to run through the tube. When the syringe has emptied, hold the syringe high and disconnect it from the tube. Clamp the tube and cover the end with the cap.
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Enteral feeding pump
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Close the flow- regulator clamp on the tubing and fill the feeding bag with a prescribed formula. I’m out use depends on agency policy. Please a label on the container with the patients name, date, and time the feeding was hung. Hang the feeding container on an IV pole. Allow the solution to flow through the tubing. Connect to the feeding pump following the manufactures directions. Set the rate. Maintain the patient in the upright position throughout the feeding. If the patient needs to temporarily lie flat, pause the feeding. Resume the feeding after the patient’s position has been changed back to at least 30 to 45°. Check placement of the tube and gastric residual every 4 to 6 hours.
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High-calorie supplements for inadequate intake
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Use only as snacks (not be used as meal substitutes) Ensure Sustacal Milk Shakes Pudding
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Enteral Feeding
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Commercially prepared enteral products Combination of carbohydrates, fat, minerals, & trace elements available in liquid form MD order Dietitian consult to select the most appropriate formula: Computes the type and amount of product needed
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Tube Feeding Indications
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Anorexia Orofacial Fractures Head/Neck Cancers Neurologic/Psychiatric Conditions Extensive Burns Chemotherapy/Radiation Stroke Severe/advanced multiple sclerosis
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Types
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Stomach NGT PEG Duodenum NDT Patient at high risk for aspiration Jejunum NJT Patient at high risk for aspiration Desirable to bypass stomach
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Nasoenteric Tubes (NGT/NDT) Advantages
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Long, soft, flexible tubes, small in diameter Small bore 8-12 Fr are preferred over large bore plastic or latex tubes Increased comfort Decreased mucosal damage Weighted tips: Easier passage of tube into pyloris Radiopaque: Position readily identified Intestinal placement decreases regurgitation of contents in the esophagus and subsequent aspiration
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Nasoenteric Tubes (NGT/NDT) Disadvantages
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More easily clogged with thick feedings More difficult to check residual volume Prone to obstruction when oral drugs not thoroughly crushed and dissolved in water Nursing Interventions: Flush tubes after oral medications Flush tubes after residual checks
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Nasogastric/Nasointestinal Tubes
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Disadvantages: Can be dislodged by vomiting or coughing Can become knotted/kinked Can become clogged Nursing Interventions: Removal and insertion of a new tube
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Gastrostomy
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Stoma created from the abdominal wall into the stomach, through which a shrt feeding tube is inserted Surgically or Endoscopically Esophageal lumen wide enough for endoscope
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Percutaneous Endoscopic Gastrostomy
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Gastrostomy tube placement via percutaneous endoscopy. Using endoscopy,a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through a stab wound made in the abdominal wall. Retention disk and bumper secure the tube
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Jejunostomy
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Indications: Chronic reflux Longterm feedings Desirable to bypass the stomach GI obstruction Abnormal gastric or duodenal emptying Advantages: Reduce risk of Aspiration
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Tube Feedings
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Immediately after insertion, tube length from insertion site to distal end should be measured and recorded Mark tube at the skin insertion site Recheck tube insertion length at regular intervals Feedings can be started when bowel sounds are present after surgical placement Approximately 24 hours post tube placement
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Placement Verification
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Check initial tube placement by X-ray Check the pH aspirant for rechecking placement (after x-ray) Properly obtained pH of 0-4 is a good indication of gastric placement pH of 6 or higher could indicate placement in the lung, intestine, or even the stomach if gastric pH is unusually high Intestinal fluid is usually bile-stained (dark golden yellow) Gastric fluid is usually grassy green, off-white to tan, or clear & colorless The auscultatory method should not be used to determine tube location
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Care and Manitenance
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Assess insertion site Check and record residual volume Q4 hours by aspirating stomach contents into syringe Increased risk for aspiration with increased residual volume If >100-200 and s/s of intolerance: Nausea and Increased abdominal girth Reinstill aspirated amount Hold next feeding for 1 hour Ensure prescribed enteral product is infused at the prescribed rate (ml/hr) Change tube feeding bag & tubing Q 24 hours Change irrigation set Q 24 hours Continuous/cyclic feedings add only 4 hours of product to the bag at a time to prevent bacterial growth Do not use blue (or any) food dye in formula
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Flushing the Tube
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Flush the tube with 30-60 ml of water (amount prescribed by health care provider) Q 4 hours during continuous tube feeding Before and after each intermittent tube feeding Before and after medication administration After checking residual volume
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Medications
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Use liquid when possible Crush tablets as finely as possible and dissolve in warm water Do not mix medications with tube feeing product
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Clogged Tube
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Use 30 ml of water to flush tube Apply gentle pressure with a 50 ml piston syringe
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Prevent Aspiration
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Elevate HOB at least 30 degrees During feeding At least 1 hour after feeding Maintain semi-Fowler’s position for clients receiving cyclic or continuous feedings
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Monitor Labs
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Blood Urea Nitrogen (BUN) Serum electrolytes HCT Prealbumin Glucose: At risk for hyperglycemia
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Formula
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Commercial formulas preferable to blenderized foods for thickness, nutrition, and contamination Lower risk of tube clogging Completeness of nutrition Decreased risk of formula contamination
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Complications
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Aspiration Fluid Imbalances: Dehydration- Excessive diarrhea, Hyperosmolar enteral preparations are delivered quickly Diarrhea- Evaluate patient for Clostridium difficle, Evaluate liquid medications Constipation Vomiting Skin irritation: Digestive juices are irritating to the skin Pulling out the tube
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Gastrostomy/Jejunostomy Care & Maintenance
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Assess insertion site for S/S of infection or excoriation Rotate the tube 360 degrees each day Check for in and out play (1/4 inch) No movement = notify HCP b/c tube may be embedded in the tissue Cover site with sterile dressing: Change dressing once a day Skin care: Keep clean and dry/rinse with sterile water Wash with mild soap and water Protective ontment: Zinc oxide/petroleumgauze Skin barrier: Karaya/stomahesive
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Partial parenteral nutrition (or peripheral parenteral nutrition)
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Nutritional support less than 14 days Supplement to oral intake Prolonged postoperative ileus Placement of central line not advised Large peripheral vein (advanced to central circulation)
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Total parenteral nutrition (or central parenteral nutrition)
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Intensive nutritional support for an extended time Delivered through subclavian or internal jugular veins Delivery of a nutritionally adequate hypertonic solution consisting of glucose, protein hydrolysates, minerals, and vitamins
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TPN Goals
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Meet the pt’s nutritional needs and allow growth of new body tissue Normal adult 1200-1500 cal/day Severe burns, surgery, malnourishment (secondary to medical treatment/disease) have greatly increased nutritional need Adequate nonprotein calories in the form of glucose and lipids must be provided to allow metabolism of amino acids for wound healing and not as energy
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Solution Preparation
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Prepared by pharmacist Nothing should be added to parenteral nutrition solutions after preparation on the pharmacy
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Administration
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Use 2.2 micron filter for solutions without fat emulsion Use 1.2 micron filter on solutions with fat emulsion Change filter and IV tubing every 24 hours Label tubing with date and time
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Complications
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Infection Metabolic problems: Hyperglycemia/hypoglycemia Hyperosmolarity/hyperglycemic state Prerenal azotemia Essential fatty acid deficiency Electrolyte/vitamin excess/deficiency Trace mineral deficiency Hyperlipidemia Mechanical problems: Air embolus Pneumothorax, hemothorax, hydrothorax Dislodgement Thrombis of great vein Phlebitis
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Nursing Management
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Verify label and MD order VS Q4-8 hours Daily weights Blood levels Dressing change to site Monitor insertion site Infusion pump must be used for administration Change TPN bag Q 24 hours Replace even if bag is not empty Solution is an excellent medium for microorganism growth at room temperature Change IV tubing Q 24 hours
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Assess catheter for related infection and septicemia
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Erythema Tenderness Exudate at catheter site Fever Chills Nausea Vomiting Malaise Nursing Intervention: Blood cultures Catheter Second location Antibiotic therapy
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Lecture TPN
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Putting in an NG tube and meet resistance = Just stop, don't go in again Position Check – HAVE to do an X-ray Stomach pH 0-4 Have to flush behind feedings very well Check placemet everytime Gastrostomy – safest way is an endoscopy tube down and come out through stomach (in to out) Jejunostomy usually for Chronic reflux Feedings start when BS RETURN pH 0-4 = good gastric placement
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TPN- how long can bag hang?
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24hrs!! * Do not add insulin to TPN bag * Check insulin q4-6hrs
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Temporary
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NASOGASTRIC & ENTERAL TUBES: usually a ____ measure to provide nutritional support.
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feeding medication
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NASOGASTRIC & ENTERAL TUBES: check tube placement prior to ____ or administering _____.
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irrigate
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NASOGASTRIC & ENTERAL TUBES: _____ to ensure it is patent
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Stroke
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: dysphagia following ____
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dysphagia
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: _____ following stroke
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bowel disease
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: inflammatory ____
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stomach
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: decompression of the ___ before or after surgery
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gastric
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: obtaining ____ specimens for analysis
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gastric lavage
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: _____ feeding or ____
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medications
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NASOGASTRIC & ENTERAL TUBES REASONS FOR USE: administration of ___
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Long term
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Percutaneous Endoscopic Gastrostomy Tubes: Generally used when a patient requires a ___ nutritional support.
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shift feeding medication
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Percutaneous Endoscopic Gastrostomy Tubes: Tube placement should be checked every ___ & before ___ or administering _____
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residual
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Percutaneous Endoscopic Gastrostomy Tubes: Before feeding or administering medications, the amount of ____ fluid in the stomach should be assessed
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Plastic nasogastric tubes
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_____: can be used for lavage, tube feeding, & administering medications.
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small bore silicon feeding tubes
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____: usually used only for tube feeding
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Percutaneous endoscopic gastrostomy (PEG) Jejunostomy
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_______(___) & ____: used for tube feeding and administering medication.
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fluids
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FEEDING PUMPS: continuous feeding effective for patients who cannot tolerate large amounts of ___ at one time
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continuous
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FEEDING PUMPS: ____ feeding effective for patients who cannot tolerate large amounts of fluid at one time
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intermittent
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FEEDING PUMPS: _____ feeding beneficial for patients who are able to feed themselves or when beginning to reintroduce oral feeding
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Physician
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FEEDING PUMPS: amount of tube feeding is prescribed by the ______.
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8 12
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FEEDING PUMPS: amount of tube feeding ranges from _ to _ oz per feeding
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catheter central vein
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TOTAL PARENTERAL NUTRITION is a method of delivering total nutrition through a ___ placed in a large _____
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TOTAL PARENTERAL NUTRITION
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A method of delivering total nutrition through a catheter placed in a large central vein.
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carbohydrates
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TOTAL PARENTERAL NUTRITION: High concentrations of ____ main source of energy.
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glucose hyperosmolality
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TOTAL PARENTERAL NUTRITION: started slowly to allow the body to adjust to the high level of ___ concentration and the ___
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Long
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TOTAL PARENTERAL NUTRITION: used for patients on ___ term therapy.
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burns intestinal bowel AIDS cancer
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TOTAL PARENTERAL NUTRITION is used for patients on long term therapy for: ____, ____ obstruction, inflammatory ___ disease, ___, _____ ( chemotherapy)
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1/2 150
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At what point would you hold a TF? If the gastric residual is greater than ___ the volume given the last feeding or greater than ___ mL when continuous feedings is in progress.
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10 minutes
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How Long should an intermittent TF be allowed to flow?
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irrigating stomach 10 20 swooshing xiphoid
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what are the different methods used to confirm proper NG placement? Use ____ syringe to aspirate ___ contents or use irrigating syringe to inject ___to___ mL of air into tube & listen with stethoscope to hear a _____ sound to the left of the ____ process
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4 once
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How often are the NG placement methods performed? every ____ hours or ___ a day depending on the situation
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Stop the feeding notify physician
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What should be done for a patient on a tube feeding who is experiencing nausea & diarrhea?
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Decompression specimen gastric lavage medicine
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What are four indications of NG intubation? 1) _____ of the stomach 2) Obtaining ____ for lab analysis 3) ___ for patients with gastrointestinal bleeding or removal of ingested toxins. 4) administration of ____
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30 90 bowel 8 tube position feeding distention
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What are four principals of tube feeding? 1) Keep HOB elevated at __to__ degrees. 2) Assess ___ sounds at least once every __hours. 3)Check ____ within GI tract before each ______. 4) Asses abdomen for ______.
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Diarrhea glycosuria
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Tube feeding solutions should be administered slowly to prevent what? ____ & ____
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3.5 5.0
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What are normal potassium serum levels? ___to___ mEq/ L
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7.35 7.45
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What are normal ABG ( ARTERIAL BLOOD GAS) levels? pH:___ – ___
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80 100
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What are normal ABG ( ARTERIAL BLOOD GAS) levels? PaO2: __- __ mm/hg
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35 45
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What are normal ABG ( ARTERIAL BLOOD GAS) levels? PaCO2: ___ – ___ mm/hg
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22 26
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What are normal ABG ( ARTERIAL BLOOD GAS) levels? HCO3: ___ – ____ mEq/ L
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7.35
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Acidosis is below ___
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7.45
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alkalosis is above ___
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carbonic respiratory bicarbonate kidneys
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In Acid-Base balance: _____ acid is retained or removed by ____ system & ____ is retained or removed by ____
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Step 1
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Assess the patients understanding of the procedure.
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Step 2
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Check the airflow through the nostrils: close one side of the nose, and check the airflow through the other.
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Step 3
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Gather all equipment needed. position patient with hob elevated 30 to 90 degrees. Raise of head of bed to working height.
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Step 4
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Hand the emesis basin close beside the patient’s with the tissues near the pillow.agree on a hand signal that will instruct you to stop if the patient experiences to much discomfort.
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Step 5
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Put on Gloves
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Step 6
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Measure the distance the tube is to the tip of the nose to the tip of the ear and then to the xiphoid process. mark it with a piece of tape.
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Step 7
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Chill or warm the tube to desired stiffness for insertion.
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Step 8
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Lubricate the tip of the tube and insert it through the nostril with the nest airflow. if changing the NG tube, insert it in the nostril other than the one previously used to avoid further irritation of the tissue. with the patients head hyperextended, aim the tube down and toward the ear. twist the tube slightly as you advance it.
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step 9
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As the tube reaches the back of the throat , have the patient take sips of water through a straw, drop the head forward, and begin to swallow.
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Step 10
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check the position of the tube as it passes down the back of the patients throat by having the patient open his mouth and hold down the tongue depressor.
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Step 11
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Advance the tube each time the patient swallows
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Step 12
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Check the placement of the tube
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Step 13
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use the irrigating syringe to aspirate stomach contents. Check the pH levels ( gastric pH is 1-4 in the stomach ad intestinal/ reparatory is greater then 6 in the trachea,)
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Step 14
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when tube is properly established and tube is secured to the the patient check by injecting 10-20mL of air in the tube with syringe and listen with stethoscope on the upper left quadrant for a swooshing sound as it enters the stomach.
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step 15
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Tape the tube securely to the face. clean the bride of nose with pad since it might be oily. apply spilt tape and spiral down the tube. secure the tape with another piece across bridge of nose.
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Step 16
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Attach to suction/ feeding tube and secure tube to gown or skin.
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step 17
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perform hand hygiene
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step 18
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assess patient for nausea and stomach distention
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step 19
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assess residual every 4 hours
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step 20
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document procedure
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Enterocutaneous fistula
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Abnormal passageway that needs to be bypassed
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Tubes that are inserted surgically are either…
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gastrostomy (terminating in the stomach) or jejunostomy tubes (terminating in the intestine)
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Tubes inserted through the nose, non-surgically, are called…
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Nasogastric or naso intestinal tubes
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Tubes that area inserted endoscopically are either…
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percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunsotomy (PEJ) tubes
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Small bore feeding tubes: Adult
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8 to 12 french. 36 to 44 inches in length. Stylet within. X-ray for placement.
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NG tube is measured from the…
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Tip of the nose to earlobe to xiphoid and mark with tape.
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When inserting an NG tube when right-handed, the nurse should stand on the….
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Right side of the patient and vice versa
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When should the patient flex head toward chest?
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Once tube has passed nasopharynx
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Which procedures should be done to check for correct placement of NG tube?
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pH testing of gastric contents, inspect aspirated fluid. Chest X-ray.
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Why does a J-tube not have a balloon?
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If the balloon was filled inside the small bowel, it would be an obstruction
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When is a J-tube typically used?
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Deliver feedings and medications in patients with aspiration problems.
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How often does the bumper of a J-tube need to be rotated?
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Daily
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What is the difference between a small and large bore tube?
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Small: Used to put fluid/feeding IN Large: Used to decompress stomach/take fluid OUT
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How often should NG tube placement be checked? How is this checked?
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Every 4 hours or as needed. Check markings, measure, aspirate and check pH.
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What is the most important assessment of any tubing?
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Skin care
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What is the GRV?
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Gastric residual volumes. How much is being absorbed vs how much is still sitting in stomach.
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When should residual be given back to patient?
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When residual is greater than 250 mL to maintain gastric pH.
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Which factors are important to positioning a patient with a feeding tube?
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HOB raised at all times (30-45 degrees). HOB remains elevated for 60 min for intermittent. HOB up at all times for continuous feedings. If patient needs to lie flat, stop feedings for 10-15 min.
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Which type of tube should the nurse never complete residual checks?
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J-tubes
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The formula should be started at what rate and strength?
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Full strength, slow rate
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How ten should the tubing be changed?
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Every 24 hours

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