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Nutrition
I.
Principles of Nutrition
The process in which the body requires food for energy in all functions,
these functions include: movement, maintenance of body temperature,
growth and development, cellular metabolism, synthesis and repair of
tissues, and organ function.
A.
Types of Nutrients
1. Carbohydrates – composed of carbon, hydrogen, and
oxygen carbohydrates are starches and sugars mainly
from plant foods. May contribute up to 90% of the total
calorie intake in some parts of the world.
Carbohydrates provide 4 kilocalories per gram. Soluble
fibers include pectin and mucilage.
a.
Carbohydrates: Any group of organic
compounds: sugar, starch, cellulose
a.1 carbohydrates provide energy and are either simple
or complex
a.2 carbohydrates are made from molecular units
called saccharides or sugar units
a.3 simple COH = have one unit of sugar (Ex.
Fructose - the sugar found in fruit)
a.4 disaccharides have two units of sugar (Ex.
Lactose-Sugar in milk and sucrose-table sugar)
*People should limit use of added sugar but not avoid
naturally occurring sugar.
a.5 complex COH - referred to as polysaccharides are
made up of long chains of glucose (sugar) units
b.
b.1
b.2
b.3
Three types of complex COH
Glycogen: body’s storage form of COH (liver,
muscle)
Starch: found in potatoes, corn, rice
Dietary fiber: nondigestible chemicals plants;
bonded in such a way the body can’t digest it.
Most fiber consumed is excreted as fiber in feces.
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c.
c.1
c.2
c.3
d.
d.1
d.2
d.3
d.4
d.5
e.
e.1
e.2
Categories of Fiber
Insoluble:
a) in vegetable, wheat, whole grain
b) softens stools
c) speeds transit time of foods in GI tract
d) reduces pressure in colon
e) prevents constipation
f) reduces risk of hemorrhoids, diverticalosis
Water Soluble:
a) in fruits, oats, barley, and legumes
b) binds with bile acids and cholesterol in the
digestive tract preventing their absorption thus
lowering the blood cholesterol
soluble fiber delays gastric emptying and provides
a feeling of fullness
Benefits of Fiber
Weight control
Blood sugar control
Reduce risk of cancer
Individuals should consume 5 servings of fruits
and vegetables and 6 servings of grain, cereal,
pasta, rice daily.
Fiber intake should be 20-35 grams daily.
Digestion and Metabolism of COH
all, except for fiber; COH is broken down into
monosaccharides then absorbed - converted to
glucose, glucose articulates in blood to cells and is
used for energy
excess COH is stored as glycogen, additional COH
is converted to fat and is stored as fat
*The brain gets most of all its energy from COH.
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2. Proteins – amino acids are the building blocks of
proteins and are made of hydrogen, oxygen, carbon,
and nitrogen. Amino acids are essential fir synthesis of
body tissues in growth, maintenance, and repair. Some
sources amino acids are available only through dietary
food sources. Proteins provide 4 kilocalories per gram.
Infants under six months of age require 2.2 g/kg/day,
healthy people require 0.8 g/kg/day, in pregnancy
women require and additional 30 g and in lactation an
additional 20 g of protein per day.
a.
a.1
a.2
a.3
a.4
a.5
makes up lean tissue and organs and
contains carbon, hydrogen, oxygen, and
nitrogen
necessary for tissue growth, repair, and
wound healing
collagen, hormones, enzymes are made for
proteins
made of smaller units called amino acid (the
building blocks of protein)
22 common amino acids that can bond to
form different proteins
9 essential amino acids must be obtained
from the diet (the body can manufacture the
others
Albumin: a plasma protein that attracts water and can pull fluid
from one body compartment to another to maintain fluid
balance
b.
b.1
b.2
b.3
Protein Classification
Complete: contains all 9 essential amino
acids for the body; generally animal origin
Incomplete: lack of one or more of the 9
essential amino acids; generally plant in
origin - ex. grains, legumes, nuts, and seeds
Vegetarian diets: mainly plant food
• The Vegan diet is strictly plant-based.
• The lacto-vegetarian diet includes
dairy and milk products.
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• The lacto-ovovegetarian diet includes
milk, dairy, and eggs.
b.4
Advantages of Vegetarian diet:
• Decreases risk for coronary artery
disease
• Decreases risk for cancer
• Decreases risk for obesity
• Decreases risk for Type II diabetes
*Strict vegetarian diet should include B12 as from fortified
cereal
c.
c.1
c.2
c.3
Digestion/Metabolism: Protein
must be broken down into smaller amino
acids units before absorption
protein metabolism is determined by the
nitrogen balance in the body
nitrogen is excreted in urine, feces, and
sweat
*If Kcal intake of protein is low, lean body tissue is broken down for
energy; the nitrogen is excreted. If the body loses more nitrogen than
it is consuming, it is in negative nitrogen balance, defined as
catabolism.
Catabolism: the breaking down phase of protein metabolism
Anabolism: the buildup phase of protein metabolism
*When nitrogen consumed is used to build tissue and isn’t excreted,
there is a positive nitrogen balance known as anabolism.
3.
Lipids – composed of carbon, hydrogen, and
oxygen these are compounds that are insoluble in
water but soluble in organic solvents such as
ethanol and acetone: and at room temperature.
Provide 9 kilocalories per gram.98% of lipids in
food and 90 % of lipids in the human body are in
the form of triglycerides. Total calorie intake
should be limited to 30% per day. Fat is how the
body’s way to store energy in the form of adipose
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fat. It also helps insulate the body from extreme
temperatures.
a.
a.1
a.2
a.3
a.4
a.5
a.6
b.
b.1
b.2
b.3
b.4
Insulate body from extreme temperatures.
Cushions the body to protect organs.
Fat is a component of membranes.
Provides satiety - feeling of fullness.
Adds flavor and aroma to food.
Provides essential fatty acids (linoleic acid
and linolenic acid).
Carries fat soluble vitamins ADEK.
Classification of Fats
Saturated:
• a fatty acid whose chemical bonds are
completely filled or saturated with
hydrogen.
• animal origin
• solid at room temperature
• saturated fats tend to increase blood
cholesterol.
Unsaturated fatty acids:
• an unsaturated fatty acid has one or
more places on its chemical chain
where hydrogen is missing
• a fatty acid with only one point of
unsaturation is called
monounsaturated
Polyunsaturated fatty acids:
• a fatty acid with two or more points of
unsaturation
• plant sources
• liquid at room temperature
• have a blood cholesterol lowering
effect at moderate levels of intake
Cholesterol: a lipid (fat)-- sterols
• offers no energy
• synthesized by liver
• found in foods of animal origin
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• plant source do not have cholesterol
*Cholesterol is highest in organ meats, egg yolk, seafood,
dairy products, and poultry.
c.
c.1
Digestion/Metabolism: Fat
Fat must be emulsified by bile from the
gallbladder.
lipoproteins are molecules made of lipids
surrounded by protein; facilitate the
transportation of lipids into the blood
Types of Lipoproteins
• HDLs (high density lipoproteins good cholesterol)
• LDLs (low density lipoproteins - bad
cholesterol)
• VLDL–very low density lipoproteins
c.2
c.3
*LDL and HDL carry cholesterol in the blood. However, LDL’s
increase the risk of atherosclerosis by contributing to plaque buildup
on artery walls.
*HDL seems to carry cholesterol to the liver where it is broken down
and excreted.
4.
Vitamins – organic substances present in small
amounts in food and are essential for normal
metabolism. The body cannot produce vitamins in
required amounts so we must depend on dietary
intake. Can be destroyed by heat, light, air, and
cooking in water. Large doses of mega-vitamins
should be avoided because of risk of toxicity
a.
a.1
a.2
Types of vitamins
Water soluble vitamins: Vitamins B & C
are not readily stored in the body; daily
intake is necessary; excess is excreted urine.
Fat soluble: Vitamins A, D, E, and K - can
be stored by the body; may only need intake
every other day.
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a.3
5.
Supplemental vitamins usually are not
necessary if diet has variety except during
pregnancy, lactation, and illness.
Minerals - inorganic single elements necessary for
body function. Less than 100mg are required
daily.
To preserve vitamins and minerals:
1.
Use little water; steam, microwave, stir-fry or bake vegetables
(avoid broiling)
2.
Store vegetables, fruits, and juices in air tight containers.
3.
Avoid high temperatures and long cooking times.
4.
Keep/use cooking water.
5.
Keep milk in opaque containers.
6.
Use food in whole form when possible.
Antioxidant Vitamins:
1.
Vitamins A, C, E - a form of beta carotene are linked to reduce
risk of certain cancers and heart disease; delay/prevent the
destruction of cell membranes in the presence of oxygen.
2.
Vitamin C promotes function of the immune system and
enhance iron absorption.
3.
Vitamin D is found in liver, egg yolks, fish, and fortified milk;
exposure to sun can help body make Vitamin D from
cholesterol.
4.
A person in nursing home not receiving milk and not going
outdoors may be at risk for vitamin D deficiency.
5.
Vitamin K is important to blood clotting, too much intake may
interfere with anticoagulates.
6.
Folic acid deficiency during pregnancy is associated with spina
bifida.
6. Water – important because the function of cells
depends on a fluid environment. Infants have the
greatest percentage of total body weight of water and
the elderly have the least. This makes them more
susceptible to water loss. The human body requires
1.5 ml if water for every kilocalorie used.
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B.
Sources of Nutrients (Web Notes)
1 gram = 9 calories
.Fat:
1 gram = 4 calories
Protein:
Carbohydrates: 1 gram = 4 calories
1 gram = 7 calories
Alcohol:
Saturated Fat:
• found mostly in meat and dairy products, as well as
some vegetable oils, such as coconut and palm oils
(tropical oils). Butter is high in saturated fat, while
margarine tends to have more unsaturated fat.
Polyunsaturated Fat: • found mostly in plant sources. (safflower, sunflower,
soybean, corn, cottonseed)
Monounsaturated Fat: • found in both plant and animal products, such as
olive oil, canola oil, peanut oil, and in some plant
foods such as avocado
Dietary cholesterol is only found in foods from animal sources, including
meat, fish, milk, eggs, cheese, and butter.
CARBOHYDRATES .
Sugars:
• monosaccharides and disaccharides
• found in fruits (sucrose, glucose, fructose, pentose), milk
(lactose), and soft drinks and sweets.
Complex
• polysaccharides
Carbohydrates: • found in whole grain cereals, flour, bread, rice, corn, oats,
potatoes, and legumes.
DIETARY FIBER Sources of fiber from highest to lowest are high fiber grain products,
nuts, legumes (kidney, navy, black and pinto beans), vegetables, fruits, and refined grain
products.
Soluble Fiber: • found in peas, beans, oats, barley, some fruits and vegetables
(apples, oranges, carrots), and psyllium.
Insoluble
• found in bran (wheat, oat, and rice), wheat germ,
Fiber:
cauliflower, green beans, potatoes, celery
PROTEIN
Meat, milk, cheese, and egg are complete proteins that have all the essential amino acids.
Other sources of protein include whole grains, rice, corn, beans, legumes, oatmeal, peas,
and peanut butter. For those who do not eat meat, eggs, or dairy products, it is important
to eat a variety of these other foods in order to get enough protein.
SODIUM Sodium is found in table salt, baking soda, monosodium glutamate (MSG),
various seasonings, additives, condiments, meat, fish, poultry, dairy foods, eggs, smoked
meats, olives, and pickled foods.
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POTASSIUM Sources: bananas, raisins, apricots, oranges, avocadoes, dates, cantaloupe,
watermelon, prunes, broccoli, spinach, carrots, potato, sweet potato, winter squash,
mushrooms, peas, lentils, dried beans, peanuts, milk, yogurt, lean meats
VITAMINS AND MINERALS
Vitamins come in two varieties: fat soluble and water-soluble. Fat-soluble vitamins can
be stored in the body for long periods of time, while excess amounts of water-soluble
vitamins are excreted in the urine.
Vitamin A
• needed for new cell growth, healthy skin, hair, and tissues, and vision in
dim light
• sources: dark green and yellow vegetables and yellow fruits, such as
broccoli spinach, turnip greens, carrots, squash, sweet potatoes, pumpkin,
cantaloupe, and apricots, and in animal sources such as liver, milk, butter,
cheese, and whole eggs.
Vitamin D
• promotes absorption and use of calcium and phosphate for healthy bones
and teeth
• sources: milk (fortified), cheese, whole eggs, liver, salmon, and fortified
margarine. The skin can synthesize vitamin D if exposed to enough
sunlight on a regular basis.
Vitamin E
• protects red blood cells and helps prevent destruction of vitamin A and C
• sources: margarine and vegetable oil (soybean, corn, safflower, and
cottonseed), wheat germ, green leafy vegetables.
Vitamin K
• necessary for normal blood clotting and synthesis of proteins found in
plasma, bone, and kidneys.
• sources: spinach, lettuce, kale, cabbage, cauliflower, wheat bran, organ
meats, cereals, some fruits, meats, dairy products, eggs.
• an antioxidant vitamin needed for the formation of collagen to hold the
Vitamin C
cells together and for healthy teeth, gums and blood vessels; improves iron
(Ascorbic
absorption and resistance to infection.
acid)
• sources: many fresh vegetables and fruits, such as broccoli, green and red
peppers, collard greens, brussel sprouts, cauliflower, lemon, cabbage,
pineapples, strawberries, citrus fruits
Thiamin (B1) • needed for energy metabolism and the proper function of the nervous
system
• sources: whole grains, soybeans, peas, liver, kidney, lean cuts of pork,
legumes, seeds, and nuts.
Riboflavin
• needed for energy metabolism, building tissue, and helps maintain good
(B2)
vision.
• sources: dairy products, lean meats, poultry, fish, grains, broccoli, turnip
greens, asparagus, spinach, and enriched food products.
Niacin
• needed for energy metabolism, proper digestion, and healthy nervous
system
• sources: lean meats, liver, poultry, milk, canned salmon, leafy green
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Vitamin B6
(Pyridoxine)
Folate (Folic
Acid)
Vitamin B12
Calcium
Iron
Phosphorus
Magnesium
Zinc
Pantothenic
Acid
Copper
Manganese
vegetables
• needed for cell growth
• sources: chicken, fish, pork, liver, kidney, whole grains, nuts, and
legumes
• promotes normal digestion; essential for development of red blood cells
• sources: liver, yeast, dark green leafy vegetables, legumes, and some
fruits
• needed for building proteins in the body, red blood cells, and normal
function of nervous tissue
• sources: liver, kidney, yogurt, dairy products, fish, clams, oysters, nonfat
dry milk, salmon, sardines
• needed for healthy bones and teeth, normal blood clotting, and nervous
system functioning
• sources: dairy products, broccoli, cabbage, kale, tofu, sardines and salmon
• needed for the formation of hemoglobin, which carries oxygen from the
lungs to the body cells
• sources: meats, eggs, dark green leafy vegetables, legumes, whole grains
and enriched food products
• needed for healthy bones and teeth, energy metabolism, and acid base
balance in the body
• sources: milk, grains, lean meats, food additives
• needed for healthy bones and teeth, proper nervous system functioning,
and energy metabolism
• sources: dairy products, meat, fish, poultry, green vegetables, legumes
• needed for cell reproduction, tissue growth and repair
• sources: meat, seafood, and liver, eggs, milk, whole-grain products
• needed for energy metabolism
• sources: egg yolk, liver, kidney, yeast, broccoli, lean beef, skim milk,
sweet potatoes, molasses
• needed for synthesis of hemoglobin, proper iron metabolism, and
maintenance of blood vessels
• sources: seafood, nuts, legumes, green leafy vegetables
• needed for enzyme structure
• sources: whole grain products, fruits and vegetables, tea
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II.
Therapeutic Diets
SERVINGS FOR THREE CALORIE LEVELS
FOOD GROUP TOTAL CALORIC INTAKE AND NUMBER OF
SERVINGS PER GROUP
_____________________________________________________________
______
1,600 calories
2,200 calories
2,800 calories
Bread
Vegetable
Fruit
Milk
Meat
6 servings
3 servings
2 servings
2-3 servings
5 ounces
9 servings
4 servings
4 servings
2-3 servings
6 ounces
11 servings
5 servings
4 servings
2-3 servings
7 ounces
A 1,600-calorie diet is about right for sedentary women and older adults.
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A 2,200-calorie is about right for most children, teenage girls, and active
women and for many sedentary men. Pregnant and lactating women may
need more calories.
A 2,800 diet is about right for teenage boys, many active men, and some
very active women.
III. Documentation
When assessing the diet and nutritional status of the client, the healthcare
provider not only is concerned with the types of foods and fluids consumed,
but also the amounts and preparation of the foods.
A.
Factors that Influence Diet
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B.
Focused Assessment and Diet History
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Nasogastric, Orogastric, and Nasointestinal Tubes
I. Intubation
A.
Intubation (placement of a tube into a structure of the body), refers to
the insertion of a tube into the stomach or intestine by way of the mouth or
nose.
1.
Orogastric intubation (insertion of the tube through the
mouth into the stomach)
2.
Nasogastric intubation (insertion of the tube through the
nose into the stomach)
3.
Nasointestinal intubation (insertion of the tube through
the nose to the intestine) are preformed to remove gas or
fluids or to administer liquid nourishment.
B.
Gastric or intestinal tubes are used for a variety of reasons,
including:
1.
Performing a gavage (providing nourishment)
2.
Administering oral medications that cannot be swallowed
3.
Obtaining a sample of secretions for diagnostic testing
4.
Performing a lavage (removing substances from the stomach,
typically poisons)
5.
Promoting decompression (removing gas and secretions from
the stomach or bowel)
6.
Controlling gastric bleeding, a process called compression or
tamponade (pressure)
II. Types of Tubes
A.
OROGASTRIC TUBE
An Orogastric tube (tube inserted at the mouth into the stomach), such as
an Ewald tube, is used in an emergency to remove toxic substances that have
been ingested. The diameter of the tube is large.
B.
NASOGASTRIC TUBES
A nasogastric tube ( tube placed through the nose and advanced to the
stomach) is the smaller in diameters than an orogastric tube but larger and
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shorter than a nasointestinal tube. A Levin tube, a commonly used, singlelumen gastric tube, has multiple uses, one of which is decompression.
C.
NASOINTESTINAL TUBES
Nasointestinal tubes ( tubes inserted through the nose for distal placement
below the stomach) are longer than their gastric counter parts. The added
length permits them to be placed in the small bowel. They are used to
provide nourishment or to remove gas and liquid drainage from the small
intestine.
1. Feeding Tubes
Nasointestinal tubes used for nutrition, such as a Keofeed tube, are usually
small in diameter and made of a flexible substance/ such as polyurethane.
Their narrow width and softer composition allows them to remain in the
same nostril for 4 weeks or longer.
Narrow tubes are not problem-free. They tend to curl during insertion
because they are so flexible. Therefore, some are supplied with a stylet
(metal guidewire) that helps straighten and support the tube during insertion.
Almost all have a weighted tip that helps them descend past the stomach.
Checking the placement of the distal end is more difficult, and these tubes
become obstructed more easily. Despite the problem associated with
maintenance, small- diameter tubes are preferred for their comfort. They are
ideal for providing a continuous infusion of nourishment.
2. Intestinal Decompression Tube
Intestinal decompression ( removal of gas and intestinal contents) is
preformed when a patient has a partial or complete bowel obstruction.
D. TRANSABDOMINAL TUBES
Transabdominal tubes (tubes placed through the abdominal wall) provide
access to various areas of the GI tract. Two examples are a gastrostomy
tube or G-tube ( transabdominal tube located within the stomach) and a
jejunostomy tube or j-tube (transabdominal tube that leads to the jejunum
of the small intestine).
III. Nasogastric Tube Management
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Nasogastric tubes are usually inserted by nurses. Nursing responsibilities
include keeping the tube patent ( or unobstructed), implementing the
prescribed use, and removing the tube when it has accomplished its
therapeutic purpose.
IV.
INSERTION
A. Patient Preparation
Most patients are anxious about having to swallow a tube. Anxiety may be
reduced by explaining the procedure and giving instructions on how the
patient can assist while the tube is being passed. One of the most important
ways to support patients is to provide them with some means of control.
B.
Assessment
Before insertion, the nurse conducts a focused assessment that includes the
patient’s:
1.
Level of consciousness
2.
Weight
3.
Bowel sounds
4.
Abdominal distention
5.
Integrity of nasal and oral mocosa
6.
Ability to swallow, cough, and gag
7.
Presence of nausea and vomiting
The main goal of the assessment is to determine which nostril is best to use
when inserting the tube and length to which the tube will inserted. Each
nostril is inspected for size, shape, and patency. The presence of nasal
polyps, a deviated septum, or a narrow nasal passage excludes a nostril for
placement.
C. Tube Measurement
Before a tube is inserted, the nurse obtains the patient’s NEX measurement
( length from nose to earlobe to the xiphoid process [tip of the sternum]; and
marks the tube appropriately. The first mark on the tube is made at the
measured distance form the nose to the earlobe. It indicates the distance to
the nasal pharynx, a location that places the tip at the back of the throat but
above where the gag reflex is stimulated. A second mark is made where the
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tube reaches the xiphoid process, indicating the depth required to reach the
stomach.
D. Placement
When inserting a nasogastric tube, the nurse’s primary concerns are to cause
as little discomfort as possible, to preserve the integrity of the nasal tissue,
and to locate the tube within the stomach, not in the respiratory passages.
1. Checking Placement
The physical assessment methods are used to determine the distal location of
a nasogastric tube are:
a.
b.
c.
d.
Aspirating fluid: If aspirated fluids appears clear brownish-yellow, or
green, the nurse can presume that its source is the stomach.
Auscultating the abdomen: The nurse instills 10 Ml or more of air
while listening with a stethoscope over the abdomen. If a swooshing
sound is heard, the nurse can infer it was caused by the air entering
the stomach.
Radiographic confirmation is the most reliable, but is costly.
Testing the PH of aspirated liquid: The first two techniques provide
only presumptive signs that the tube is in the stomach, but testing PH
provides confirmation of acidic gastric contents. Instill 30ml of air to
rid the tube of formula, medication, or flush solution. 5 to 10 ml of
fluid are aspirated from the tube, the pH should test 7.8 to 8.0, those
on acid inhibitors may test at 4.0 to 6.0.
Once stomach placement is confirmed, the tube is secured to avoid upward
or downward migration.
V.
USES AND MAINTENANCE
Nasogastric tubes are connected to suction for gastric decompression or are
used for tube feeding.
A.
Promoting Patency
Tube patency is promoted by giving ice chips or occasional sips of water to
a patient who is otherwise NPO. The fluid helps dilute the gastric secretions.
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However, both must be given sparingly because water is hypotonic and
draws electrolytes into the gastric fluid. Because the diluted fluids is
ultimately removed, giving the patient liberal amounts of water can deplete
serum electrolytes.
B.
Restoring Patency
The nurse assesses tube patency frequently by monitoring the volume and
characteristics of drainage and observing for signs and symptoms suggesting
an obstruction (nausea, vomiting, and abdominal distention). Sometimes the
nasogastric tube must be irrigated to maintain or restore patency. A medical
order must be obtained before attempting an irrigation.
VI.
REMOVAL
Unobstructed larger-diameter tubes are usually removed and changed at least
every 2 to 4 weeks for adults. Small- diameter, flexible tubes are removed
and changed every 6 weeks to 3 months, depending on agency policy. Tubes
used for pediatric patients are changed more frequently. Before permanent
removal, some physicians prescribe a trial period during which the tube is
clamped and the patient is allowed to consume oral fluids.
VII. Tube Feedings
It is always best to provide nutrition by the oral route. However, if oral
feedings are impossible or jeopardize the patient’s safety, nourishment is
provided enterally or parenterally. Tube feedings are used when patients
have undergone extensive mouth surgery, have difficulty swallowing, or
have esophageal or gastric disorders, or head or neck injuries.
A.
BENEFITS AND RISKS
Instilling nutritional formulas into the stomach uses the body’s natural
reservoir for food. It also reduces the potential for enteritis (inflammation of
the intestine) because the chemical in the stomach tend to destroy
microorganisms. However, gastric feeding creates a greater potential for
gastric reflux because of their volume and temporary retention within the
stomach.
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B.
FORMULA CONSIDERATIONS
In addition to the type of tube and the access site, the type of formula is also
individualized, based on the patient’s weight, nutritional status, and
concurrent medical conditions and the projected length of therapy. The
feeding schedule also affects the choice of formula.
C. TUBE-FEEDING SCHEDULES
1.
Bolus Feedings
A bolus feeding( instillation of liquid nourishment four to six times a day in
less than 30 minutes) usually involved 250 to 400 mL of formula. This
schedule is the least desirable because it distends the stomach rapidly,
causing gastric discomfort and increase risk of reflux. Patient who are
unconscious or who have delayed gastric emptying are at greater risk for
regurgitation, vomiting, and aspiration when this method of administration is
used.
2.
Intermittent Feedings
An intermittent feeding (gradual instillation of liquid nourishment four to
six times a day) is administered over 30 to 60 minutes, the time most people
spend eating a meal. The usual volume is 250 to 400 Ml. Intermittent
feedings are generally given by gravity drip from a suspended container or
with a feeding pump. Tube-feeding administration sets are replaced every
24 hours regardless of the feeding schedule. Begin feedings with no more
than 150 to 250 ml at one time then increase by 50 ml per day until
desired volume is met and increase at 10 to 20 ml/hr per day.
3.
Cyclic Feeding
A cyclic feeding(continuous instillation of liquid nourishment for 8 to 12
hours)is followed by a 16-to 12-hour pause. This routine is often used to
wean patients from a tube feedings while continuing to maintain an adequate
amount of nutrition.
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4.
Continuous Feeding
A continuous feeding(instillation of liquid nutrition with out interruption) is
administrated at a rate of approximately 1.5 ml/minute. A feeding pump is
used to regulate the instillation. Only 4 hours of formula can be hung at one
time in an open system and in a closed system the formula can hang 24
hours.
VIII.
PATIENT ASSESSMENT
The following daily assessments are standard for almost every patient who
receives tube feeding: weight, fluid intake and output, bowel sounds, lung
sounds, temperature condition of the nasal and oral mucous membrane,
breathing pattern, gastric complaints, abdominal distention, vomiting, bowel
elimination patterns, and skin condition at the site of a transabdominal tube.
Once tube feedings have been initiated, it is also necessary to assess the
patient’s gastric residual on a routine bases.
Check residuals every 8 to 12 hours, fingersticks every 6 hours until the
maximum rate is established then every24 hours, I & O every 8 hours,
weight every day until the maximum rate is established then 3 times a
week.
A. Gastric Residual
Gastric Residual (volume of liquid within the stomach) is measured to
determine whether the rate or volume of feeding exceeds the patient’s
physiologic capacity.
Overfilling the stomach can cause gastric reflux, regurgitation, vomiting,
aspiration, and pneumonia. As a rule of thumb, the gastric residual should
be no more than 100 ml, or no more 20% of the previous hour’s tube-feeding
volume.
X1. NURSING MANAGEMENT
Caring for patients with feeding tubes generally involves maintaining tube
patency, clearing any obstructions, providing adequate hydration, dealing
with common formula-related problems, and preparing patients for home
care.
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Nutrition
A.
Common cause of obstruction are using formulas with large-molecule
nutrients, refeeding partially digested gastric residual, administering
formula at a rate less than 50 ML/hour, and instilling crushed or
hydrophilic medications to the tube.
To maintain patency, it is best to flush feeding tubes with 30 to 60 ml
immediately before and after administering a feeding or medications,
every 4 to 6 hours if the patient is being continuously fed, and after
refeeding the gastric residual.
B.
If an obstruction occurs, the physician is consulted. Occasionally it is
possible to clear the tube with a solution of meat tenderizer or
pancreatic enzyme, but both require written medical orders. When an
obstruction cannot be cleared, the tube should be removed and another
inserted rather than compromising nutrition by the delay.
Although tube feedings are approximately 80% water, patients usually
require more hydration. Adults require 30 ml of water per kilogram of
weight, or 1 ml/kcal, on a daily basis.
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