Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Chapter 44 Nutrition /Naso-Gastric Tubes ATI Skill Checklist N/G Tube Insertion Gastrostomy Tube Feeding/Med Administration Managing Suction N/G Tube Decompression Background Food security is critical for all members of a household. Food holds symbolic meaning. Medical nutrition therapy uses nutrition therapy and counseling to manage disease. Type 1 diabetes mellitus Hypertension Inflammatory Enteral bowel disease nutrition (EN); parenteral nutrition (PN) Case Study Mrs. Gonzalez is a 65-year-old Hispanic woman who comes to the emergency department with slurred speech, right facial droop, and weakness in her upper and lower right-side extremities. She is admitted to the hospital with a diagnosis of acute stroke. She has a daughter and two teenage grandchildren who live in another town nearby. Energy Requirements Basal metabolic rate—the energy needed to maintain life-sustaining activities for a specific period of time at rest Resting energy expenditure (REE) (aka resting metabolic rate)—the amount of energy that an individual needs to consume over a 24-hour period for the body to maintain all of its internal working activities while at rest In general, when energy requirements are completely met by kilocalorie intake in food, weight does not change. Scientific Knowledge Base: Nutrients Water All cell function depends on a fluid environment. Vitamins Essential for metabolism Water-soluble or fat-soluble Minerals Catalysts for enzymatic reactions Macrominerals; trace elements Digestion Digestion Absorption Begins in the mouth and ends in the small and large intestines Intestine is the primary area of absorption. Metabolism and storage of nutrients Elimination Consist of anabolic and catabolic reactions Chyme is moved through peristalsis and is changed into feces. Dietary Guidelines Dietary reference intakes (DRIs) Acceptable range of quantities of vitamins and minerals for each gender and age group Food guidelines Dietary Guidelines, average daily consumption Daily values Needed protein, vitamins, fats, cholesterol, carbohydrates, fiber, sodium, and potassium Case Study (cont’d) Mrs. Gonzales is awake and alert in her hospital room, yet is drooling from the right side of her mouth. When she tries to drink water, she starts to cough. The physician has ordered nothing by mouth (NPO). Evaluation by the speech language pathologist (SLP) indicates inadequate clearance of food and liquid from the vocal folds and aspiration of thickened liquids. Mrs. Gonzalez has trouble swallowing with oropharyngeal dysphagia. The SLP recommends enteral feedings, and speech and swallowing therapy to help her return to oral feedings. Case Study (cont’d) Matt is a nursing student assigned to Mrs. Gonzalez. As he prepares to assess her, he recalls information about the effects of dysphagia on nutrition and rehabilitation. He will assess Mrs. Gonzales’ weight, weight history, diet history, and cultural customs. Matt knows to consult with a registered dietitian (RD) to assess Mrs. Gonzales’s nutritional status and interventions. Matt is responsible for inserting Mrs. Gonzalez’s small-bore nasogastric feeding tube and starting her tube feedings. The RD has recommended continuous tube feeding for 12 hours during the day. Assessment Screening a patient is a quick method of identifying malnutrition or risk of malnutrition using sample tools: Height Weight Weight change Primary diagnosis Comorbidities Screening tools Assessment (cont’d) Anthropometry is a measurement system of the size and makeup of the body. An ideal body weight (IBW) provides an estimate of what a person should weigh. Body mass index (BMI) measures weight corrected for height and serves as an alternative to traditional height-weight relationships. Laboratory and biochemical tests Assessment (cont’d) Dietary and health history Health status; age; cultural background; religious food patterns; socioeconomic status; personal food preferences; psychological factors; use of alcohol or illegal drugs; use of vitamin, mineral, or herbal supplements; prescription or over-thecounter (OTC) drugs; and the patient’s general nutrition knowledge Physical examination Dysphagia (difficulty swallowing) Case Study (cont’d) Assessment findings: Mrs. Gonzales starts to cough when she tries to drink water. Mrs. Gonzales is unable to swallow and aspirates pills and thickened liquid. Lung sounds are clear. Respirations are regular at 12/min. She has no dyspnea. Oxygen saturation is 96% on room air. Enteral nutrition will begin at 60 mL/hr. Nursing Diagnosis Risk for aspiration Deficient knowledge Diarrhea Readiness for enhanced nutrition Imbalanced nutrition: more than body requirements Feeding self-care Impaired swallowing deficit Imbalanced nutrition: less than body requirements Risk for imbalanced nutrition: more than body requirements Case Study (cont’d) Diagnosis: Risk for aspiration related to impaired swallowing Goals: Mrs. Gonzales will receive adequate nutrients through enteral tube feeding without aspiration by the time of discharge. Mrs. Gonzalez will regain swallowing ability from speech therapy by the time of discharge. Planning Nutrition education and counseling are important for all patients to prevent disease and promote health. Refer to professional standards for nutrition. Collaboration with a registered dietitian (RD) helps develop appropriate nutrition treatment plans. Considerations: Perioperative food intake Enteral and parenteral feedings Assistive devices Other Causes of Dysphagia Obstructive lesions in the throat or esophagus, such as tumors Central nervous system infections Head injury Cerebral palsy Parkinson's disease Huntington's disease 17 Some causes of dysphagia include: Myasthenia gravis Amyotrophic lateral sclerosis (ALS) Multiple sclerosis Scleroderma Infection with herpes simplex virus or yeast Narrowing of the esophagus after infection or irritation Injury to the swallowing muscles from chemotherapy and radiation for cancer 18 Enteral Tube Feeding Enteral nutrition (EN) provides nutrients into the GI tract. It is physiological, safe, and economical nutritional support. Nasogastric, Surgical jejunal, or gastric tubes or endoscopic placement Nasointestinal Gastrostomy Jejunostomy PEG (percutaneous endoscopic gastrostomy) PEJ (percutaneous endoscopic jejunostomy) Risk of aspiration 20 •Enteral Tubes Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to 44 inches long. A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is removed when correct positioning of the feeding tube is confirmed. NG TUBE INSERTION Ear lobe to xiphoid process Ear lobe to Nose Tip 22 23 24 Chest Xray Representing a Properly placed NG tube 25 Chest xray NG tube in left main stem Bronchi 26 27 pH Measurement for Tube Location See Box 44-13 on text p. 1020 29 Benzocaine Spray Viscous Lidocaine 30 TYPES OF NASOGASTRIC TUBES The first nasogastric tubes were made of soft rubber. Recently, tubes have been made of silastic and polyethylene compounds. These tubes can be inserted more easily and also cause fewer medical problems for the patient. There are fewer instances of inflamed tissues. With the exception of this change, nasogastric tubes are very much the same today as they have been for the last three decades. The most commonly used nasogastric tube is the Levin tube. Other nasogastric tubes include the Salem-sump tube, the Miller-Abbott tube, and the Cantor tube. 31 The Levin Tube The actual tubing is referred to as lumen. The Levin tube is a one-lumen nasogastric tube. The Salem-sump nasogastric tube is a two-lumen piece of equipment; that is, it has two tubes. The Levin tube is usually made of plastic with several drainage holes near the gastric end of the tube. There are graduated patient depth markings. This nasogastric tube is useful in instilling material into the stomach or suctioning material out of the stomach. 32 33 Case Study (cont’d) Nutritional management Insert feeding tube as ordered. Initiate enteral feeding as prescribed. Advance tube feeding as tolerated; monitor for tolerance. Aspiration precautions Position Mrs. Gonzalez with head of bed elevated a minimum of 30 degrees. Check tube placement every 4 to 6 hours. Check gastric residual volume every 4 hours. Continue with speech therapy. ENTERAL TUBE FEEDING COMPLICATIONS TABLE 44-7 (Pg.1022) Pulmonary Aspiration Diarrhea Constipation Tube Occlusion Tube Displacement Abdominal Cramping-Nausea/Vomiting Delayed Gastric Emptying Serum Electrolyte Imbalance Fluid Overload Hyperosmolar Dehydration 35 Quick Quiz! 2. You receive an order to begin enteral tube feedings. The first step is to A. Place the patient in a prone position. B. Irrigate the tube w/normal saline. C. Check to see that the tube is properly placed. D. Introduce a small amount of fluid into the tube before feeding. Parenteral Nutrition Nutrients are provided intravenously. Patients unable to digest or absorb enteral nutrition or are in highly stressed physiological states: Sepsis Head injury Burns Peripheral or central line Initiating parenteral nutrition Preventing complications Restorative and Continuing Care Medical nutrition therapy (MNT) Specific nutritional therapy usage for treating illness, injury, or a certain condition Necessary for Metabolizing Correcting certain nutrients nutritional deficiencies Eliminating foods that worsen disease states Most effective with collaborative health care team and dietitian Case Study (cont’d) What nursing actions are appropriate for evaluating whether goals have been met? Consider Check the patient’s perspective. measurable outcomes. Consult with interdisciplinary staff. Evaluation Multidisciplinary collaboration remains essential in providing nutritional support. Changes in condition indicate a need to change the nutritional plan of care. Consider the limits of patients’ conditions and treatments, their dietary preferences, and their cultural beliefs when evaluating outcomes. Case Study (cont’d) Matt sees Mrs. Gonzalez before discharge to a restorative care facility for rehabilitation before returning home. Mrs. Gonzalez now is able to consume all of her required nutrients with a ground diet and nectar-thickened liquids. Matt removes the feeding tube in preparation for her transport to the new facility. Matt advises Mrs. Gonzalez to continue the care plan and emphasizes that it is important to continue speech therapy. 42 NG Tubes for Decompression Refer to ATI (Accepted Practice) N/G intubation is used for several purposes: to decompress the stomach and remove gas and fluid, to lavage the stomach to remove ingested toxins, to diagnose problems with GI motility, to treat an obstruction, to compress a bleeding site, to aspirate contents for a gastric analysis, and to administer contrast for a radiographic study. 43 The Miller-Abbott Tube (Active Gastric Hemorrhage) 44 45 46 NG Tubes for Decompression Gastric decompression is indicated for obstruction or paralytic ileus and when surgery is performed on the stomach or intestine. The tube usually remains in place until normal bowel function returns as evidenced by normal bowel sounds on auscultation and/ or when the pt. begins to pass flatus. 47 The Salem-Sump Tube This nasogastric tube is a two-lumen piece of equipment. It has a drainage lumen and a smaller secondary tube that is open to the atmosphere. The major advantage of this two-lumen tube is that it can be used for continuous suction. The continuous airflow reduces the frequency of stomach contents being drawn up into the whole of the lumen which is in the patient's stomach. 48 49 50 NG Tubes for Decompression With gastric decompression, stomach contents are removed to relieve the stomach and intestines of the pressure caused by the accumulation gastrointestinal air and fluid. The N/G tube is connected to suction to facilitate decompression by removing the contents. 51 52 Postoperative Gastrointestinal Discomfort Postoperative gastrointestinal discomfort is not new. The earliest written records described an unchanging physiological response following any type of surgery, with greater severity after laparotomy. Clinically, there are three typical consequences of surgery, namely dilatation of the stomach, ileus and PONV. (Post-Op Nausea & Vomiting) 53 Postoperative Gastrointestinal Discomfort Dilatation of the stomach is related to the common postoperative increase in swallowing [1]. Air carried into the stomach with each swallow induces gastric discomfort, and when present in great quantities the air passes into the intestine, resulting in abdominal distension. The greatest incidences were found in patients who had undergone surgery to the biliary tract or uterus. In the majority of the cases, distension was apparent after 24 hours and the usual duration was 48 to 72 hours [2]. 54 Postoperative Gastrointestinal Discomfort Decompression relieves gastric discomfort, but the irritating presence of the tube promotes swallowing. In any case, these physiological events must be distinguished from acute gastric dilatation and acute colonic pseudo-obstruction, which are responsible for major abdominal distension in very specific circumstances. 55 Mechanisms of postoperative gastrointestinal discomfort 56 NG Tubes for Decompression For some patients the tube is placed during surgery and used post-op for gastric decompression. This is usually used for patients who undergo extensive surgery or who are at a high risk for prolonged postoperative ileus. Follow the surgeon’s post op order for specific instruction on suction, irrigation etc. 57 GASTRIC LAVAGE Gastric Lavage is the irrigation of the stomach. This is usually performed is acute care settings where poisonings or drug overdoses for which swift removal of stomach contents is required. In this situation an orogastric or nasogastric tube is inserted both to aspirate gastric contents and to instill a rinsing solution into the stomach to dilute the toxic substance. 58 BIG RED 59 GASTRIC LAVAGE Patients who have gastric bleeding are sometimes treated with iced saline lavage, which involves instillation and aspiration of iced saline through an N/G tube to empty the stomach of blood and to slow the bleeding (vasoconstriction) at its source. (Controversial due to the Vasovagal response which increases acid reflux) Norepinephrine is sometimes used as a vasoconstrictor at the site but the hypertensive response must be closely monitored. Lavage may also be used as therapy for hypo or hyperthermia to help stabilize body temperature. 60