Chapter 19: Nutritional

Nutrition- sum of all interactions between an organism and the food it consumes. Nutrients are organic and inorganic substances found in foods that are required for body

functioning. Adequate food intake consists of a balance of: water, carbs, proteins, fats, vitamins, and

minerals. No one food provides all essential nutrients. Nutrients have three major functions:

◦ Provide energy for body processes and movement◦ Provide structural material for body tissues◦ Regulating body processes

Essential Nutrients Body's most basic nutrient need is water to provide energy. Energy-providing nutrients: carbs, fats, and proteins. Macronutrients: nutrients needed in large amounts

◦ carbohydrates, fats, proteins, minerals, vitamins, and water. Micronutrients: nutrients required in small amounts used to metabolize the energy-providing

nutrients. ◦ vitamins and minerals

Carbohydrates CHO: simple carbohydrates (sugars) and complex carbohydrates (starches and fiber) Natural sources of carbohydrates supply other vital nutrients that processed foods cannot. Types of carbohydrates:

◦ Sugars◦ Starches: insolube, nonsweet forms of carbohydrates. (grains, legumes, potatoes, puddings) ◦ Fiber: complex carbohydrates derived from plants that add roughage (bulk) to the diet.

▪ Satisfies appetite and helps GI tract function effectively.▪ Outer layer of grains, bran and in the skin, seeds, and pulp of fruits and veggies.

Digestion:◦ Ptyalin (salivary amylase), pancreatic amylase and disaccharidases. ◦ ALL monosaccharides are absorbed by the small intestine.

Metabolism:◦ Glucose circulates in blood as a readily available source of energy. ◦ Remainder is stored into the cells by insulin or glucose-4.

Storage◦ Glucose stored as glycogen in liver and skeletal muscles. ◦ Glucose that cannot be stored as glycogen is stored as fat instead.

Proteins Essential amino acids: cannot be manufactured in the body and must be supplied by diet.

◦ 9 essential amino acids

Nonessential amino acids: can be manufactured in the body. Complete proteins: contain all of the essential amino acids plus some nonessential ones..

◦ Most animal products are complete proteins. ▪ Exceptions: gelatin and milk protein casein.

Incomplete proteins: lack on or more amino acids (most comomnly lysine, methionine, or tryptophan) ◦ Usually derived from vegetables. ◦ Combination of incomplete proteins that provide all the essential amino acids is called

complementary proteins. Digestion:

◦ Pepsin in mouth breaks down protein. ◦ Pancreatic enzymes: trypsin ◦ Intestinal enzymes: aminopeptidase.

Storage:◦ absorbed in small intestine ◦ sent to liver so that liver can synthesize plasma proteins and other things for the body.

Metabolism◦ Anabolism vs catabolism◦ Nitrogen balance: measure of the degree of protein anabolism and catabolism.

▪ Negative nitrogen balance = more catabolism of proteins.

Lipids Digestion:

◦ digested in the small intestine▪ digested by bile and lipase.

Broken down into glycerol, fatty acids, and cholesterol. ◦ Immediately reassembled into triglycerides and cholesterol which are fat-

soluble. ▪ Sent to liver to be reconverted into water-soluble lipoproteins.

Metabolism◦ Converting fat into usable energy occurs when triglycerides are broken into glycerol and

fatty acids. ◦ 1 lbs = 3500 kcal◦ Fasting people receive most of their calories from fat metabolism, but carbohydrate and

protein metabolism is needed for the brain, nerves and RBC's. Micronurtrients

Vitamin: organic compound that cannot be manufactured by the body. ◦ Water-soluble vitamins: vitamin C, vitamin B-complex ◦ Fat-soluble vitamins: A, D, E, and K.

Minerals: inorganic compounds found as free ions in organic compounds. ◦ Macrominerals: required in more than 100mg/day: Ca, P, Na, K, Mg, Cl, and S. ◦ Microminerals: required in less than 100mg/day: Fe, Zn, Mn, I, Fl, Cu, Co, Cr, Se

▪ iron-deficiency anemia and osteoporosis

Energy Balance

Energy Intake Calorie: unit of heat energy

Energy Output Metabolism: process by which the body grows and maintains itself; rate of eat liberated during

chemical reactions Basal metabolic rate (BMR): rate at which the body metabolizes food to maintain energy

requirements of a person awake and at rest. Activity; Calculated by measuring REE in morning, 12 hrs after eating

Resting energy expenditure (REE): energy to maintain basic body fns. (maintain life).

Body weight and Body Mass Standards Balance b/w expenditure of energy and intake of nutrients Ideal body weight (IBW): Optimal weight for optimal health.

◦ Rule of 5 F, 6 M ▪ Female: 100lb for 5ft + 5(every in over 5ft), (+/-)10% for body-frame size▪ Male: 106 for 5ft + 6(ever in over 5ft), (+/-) 10% for body-frame size

BMI: changes in body fat stores, weight appropriate to height. Caution for fluid retentive people, athletes, or older adults.

Factors Affecting Nutrition ◦ Development

▪ Periods of growth (increased needs)▪ Older adults need less calories and may face dietary changes related to coronary heart

disease, osteoporosis, and hypertension.

◦ Sex▪ Larger muscle mass, pregnant, lactating = greater need of calories and proteins, fluid▪ Women prior to menopause- more Fe

◦ Ethnicity and culture▪ Just follow “universally” accepted guidelines: eat variety for adequate nutrients and

moderately ▪ Af.americans: many lactose intolerant, high in fat & Na, curvy ok ▪ Arab: Spices, bread every meal, muslims no pork, Ramadan, feed w/ R.hand▪ Chinese: served in specific order, lactose int., balance yin/yang avoid indigestion ▪ Jewish: pork forbidden, meat&milk not together▪ Mexican: hot&cold theory, sweet drinks popular ▪ Navajo: herbs, sheep major, squash&corn major, lactose int.

◦ Beliefs about food ▪ Fads/myths: support and suggest more nutritious diets

Examples of fads and myths:◦ yogurt and vitamin E slow down aging.◦ Honey is healthier than sugar, and a cure for the common cold. ◦ Eating cabbage and onions turns breast milk sour◦ Raw eggs, lean beef, and oysters increase sexual potency.◦ Organic foods are always healthier than those exposed to pesticides.

◦ Stomach enzymes cannot work on vegetables and fish at same there, therefore both should not be eaten together.

◦ Personal preferences ▪ Taste, smells, flavor, temp, color, shape, size, texture

◦ Religious Practices▪ Orthodox Judaism/islam: prohibit pork▪ Protestant faiths: prohibit meat, tea, coffee, or alcohol▪ Orthodox jew: kosher (inspected by rabbi)

◦ Lifestyle▪ Cooking skill, concern about health, work schedules▪ Muscular activity- the more strenuous, the greater the metabolism stimulation

◦ Economics ▪ Higher income: more protein, fat, fewer complex carbs

◦ Meds and Therapy▪ Alter appetite, drug utilization, old people on many meds (high chance of drug

interactionss) ▪ Calcium in milk hinders tetracycline, but enhances erythromycin. ▪ Antineoplastic agents (oral ulcers, GI bleeding, diarrhea) = diminish nutritional status▪ Radiotherapy- depending on locaton; swallowing difficult, n&v, fatigue

◦ Health▪ Missing teeth, ill fitting dentures, sore mouth▪ Dysphagia: inflamed throat or stricture of esophagus cause inadequate nourishment ▪ GI surgery (digestion, absorption, metabolism, excretion)▪ Gallstones (impaired lipid digestion), ▪ Liver disease (impair metabolic processes), ▪ Pancreas (impair glucose metabolism, fat digestion)

◦ Alcohol consumption ▪ Lead to weight gain (small amount converted directly to fat)▪ Remainder converted to acetate by liver (released for energy instead of fat) ▪ Depress appetite, affect intestinal mucosa, increased need for vit.B (alcohol

metabolism), impair nutrient storage and excretion

◦ Advertising ▪ Influence choices and eating patterns ▪ Convenience foods, take out, kids (sweets), elders (supplements)

◦ Psychological ▪ Anorexia nervosa, bulimia▪ Overeat when stressed, depressed, or lonely

Nutritional Variations Throughout the Life Cycle

◦ Neonate to 1 year▪ Newborns:

Newborns fed on “demand”: feed when hungry, not on set schedule Higher metabolic rate, immature kidneys, greater h2o loss = greater fluid needs 80-100 mL breast milk/formula, Q2.5h-Q4h, then solids slowing of sucking or fall asleep when satisfied Reduce SIDS by placing in supine for first 6 months Regurgitation may occur in the first year, but it is not usually result in nutritional

deficiency. ▪ 6 months:

addition of solid food to diet: able to sit up, hold spoon, and reduced sucking an tongue protrusion reflex (from bottle/breast feeding)

Solid foods are usually strained or pureed. ◦ Cereals (rice) → fruits → vegetables → and strained meats.

▪ Require Fe supplements prevent anemia (6-18 m)▪ Bottle mouth syndrome: teeth decay by constant contact with sweet

◦ Toddler ▪ 33 lbs.= 1250 mL per 24 hrs.▪ Caloric Requirement: 900-1800 kcal/day. ▪ Should mix between adult table food and toddler foods progressively moving away from

toddler foods due to decreased nutritional value. ▪ Common nutritional deficiencies among toddlers: Fe, Ca, and Vitamins A and C. ▪ solid food, 3x/day▪ Education on how parents can meet the child's nutritional needs and promote effective

parent-child intereactions: Make mealtime a pleasant time by avoiding tensions and discussing bad behaviors Offer variety of simple, attractive foods in small portions Do not use food as a reward or punish a child who does not eat Schedule meals, sleep, and snack times that allow for optimum appetite and

behavior. Avoid routine use of sweet desserts.

◦ Preschooler▪ Very active; rush through meals. Require snacks▪ 45 lbs.= 1500 mL

◦ School age▪ Protein-rich for physical and mental effort at school ▪ Breakfast important ▪ Dinner very important family time ▪ 2,400 kcal/day ▪ 66 lbs.=1750 mL▪ Eating habits and regular exercise important and learned by parents

◦ Adolescent

▪ Protein, Ca, vit.D, B▪ Obesity, depression, anorexia nervosa, bulimia▪

◦ Young adult▪ Be aware of serving▪ Fe intake (18mg for menstruating)- organ meats, eggs, fish, poultry, leafy veggies, dried

fruit▪ Folic acid for child-bearing (prevent birth defect)▪ Calcium and Vitamin D needed to maintain bones and decreases risk for osteoporosis

later in life. ▪ Prevention of CV disease, obesity

◦ Middle-aged adult▪ Protein, Ca, limit cholesterol and calories▪ 2-3 L of fluid▪ Decreased metabolic activity and decreased activity means decreased caloric need. ▪ Postmenopausal: Ca, Vit.D reduce osteoporosis, antioxidants= CV disease▪ late middle age: decreased gastric juice secretions and free acid “heartburn”

◦ Older adults▪ Fewer calories (lower metabolic rate and activity)▪ Decreased saliva, gastric juice secretions ▪ Difficulty sleeping at night (major meal at noon)▪ Difficulty chewing (dentures, losing teeth, difficult foods to chew) ▪ Lowered glucose tolerance (complex carbs, fiber rather than sugar-rich)▪ Neuromuscular/dysphagia: chin-tuck method, thicker consistency▪ Decreased social interaction, loneliness (▪ Loss of appetite and senses of smell and taste (eat essential and nutritious food first,

then better tasting food last)▪ Limited income (generic foods, foods on sale freeze for later, avoid convenience foods)

Standards for a healthy diet ◦ Dietary Guidelines

▪ Daily totally fat intake 20-35% of total calories▪ Less than 1,500 mg of sodium /day ▪ Alcohol (1-women, 2-men/day)

◦ Dietary Reference Intakes ▪ DRI: Standards for nutritent recommendations that include the following values:

Estimated avg. requirements (EARs): ◦ average daily nutrient intake value estimated to meet the requirement of half the

healthy individuals in a particular life stage and gender group. Recommended dietary allowances (RDAs)

◦ Average daily nutrient intake level sufficient to meet the nutrient requirement of nearly all healthy individuals.

Adequate Intakes (AI)◦ when RDA cannot be determined. ◦ Recommended average daily nutrient intake level based on approximations.

Tolerable Upper Intake Levels (UL)

◦ highest average daily nutrient intake level likely to pose no risk to individuals.

◦ Vegetarian Diets▪ Need complementary protein diet & Fe (leafy greens, whole grains, raisins, molasses) &

Ca (soymilk, tofu)▪ Animal origin (vit.B12), vegans need brewer’s yeast

Altered Nutrition ◦ BMI (25-29.9): overweight (greater than 30): obese◦ Excess body weight: Increased stress on organs and predisposes people to chronic health

problems. May even suffer from undernourishment even though excess calories are ingested.

◦ Undernutrition: intake of nutrients insufficient to meet daily energy requirements because of inadequate food intake or improper digestion and absorption of food. ▪ Improper digestion: inadequate hormones/enzymes, inflammation/obstruction of GI

tract ▪ When undernourished, carb reserves (stored as liver &muscle glycogens) can only used

for 24 hrs before protein is used for energy. ◦ Protein-calorie malnutrition (PCM): starving children & chronic/cancer,

▪ Characteristics: depressed visceral proteins (albumin), weight loss, and visible muscle and fat

wasting ◦ Somatic proteins (skeletal muscle mass)

▪ Assessed by measuring the mid-arm circumference (MAC)▪ Mid-arm muscle area (MAMA)

◦ Visceral proteins (plasma proteins, hemoglobin, hormones, antibodies)▪ Assessed through Lab Data: serum protein levels such as albumin and transferrin

~ Nursing Management ~Assessing

Nursing History◦ Diet History:

▪ Difficulty chewing or swallowing▪ Inadequate budget, food intake, food prep facilities, food storage.▪ IV fluids▪ Living or eating alone▪ Physical disabilities▪ Restricted or fad diets

◦ Medical History:▪ Adolescent pregnancy or closely spaced pregnancies▪ Substance abuse▪ Burns and/or trauma▪ Chronic illness▪ Fluid and electrolyte imbalances▪ GI problems▪ Neuro or cognitive impairments

▪ Oral or GI surgery▪ Unintentional weight loss

◦ Medication History▪ Antacids▪ Antidepressants▪ Antihypertensives▪ Anti-inflammatory▪ Antineoplastic▪ Diuretics▪ Laxatives▪ KCl▪ Aspirin▪ Digitalis

Nutritional Assessment ◦ ABCD

▪ (A)nthropometric Data:◦ height/weight◦ IBW, usual body weight, BMI◦ In-depth data:

▪ Triceps skin fold, MAC, MAMA▪ (B)iochemical Data (Lab data)

◦ H/H (enough nutrition to make RBC)◦ Serum albumin◦ Lymphocyte count◦ Vitamins and Folate levels◦ In-depth data:

▪ Serum transferrin levels, UUN, U-creatinine, hair analysis, neuro testing ▪ (C)linical Data (physical assessment)

◦ skin (pale, dry, flaky)◦ hair and nails (brittle. pale)◦ Mucous membranes◦ Gums (spongy, swollen, inflamed , bleed easily due to Vit. C deficiency) ◦ tongue (glossy, smooth, swollen)◦ GI system: indigestion, diarrhea, constipation, enlarged live◦ Nervous system: decreased reflexes, sensory loss, mental confusion or irritability

◦ activity data▪ (D)ietary data:

24hr food recall food frequency record food diary diet history

◦ allergies, food taste, chewing problems

Imbalanced nutrion Readiness for enhanced nutrition Risk for imbalanced nutrition

Activity intolerance R/t inadequate intake of Fe Constipation r/t inadequate fluid and fiber intake Low self-esteem r/t obesity Risk for infection r/t immunosuppression secondary to insufficient protein intake

Planning Incorporate ability for self-care, financial resources

Implementing Clear liquid diet

◦ Water, tea, coffee, clear broths, soda, plain gelatin.◦ Fluid and carbs (24-36 hrs.) post-op, or acute stages of infection (GI)◦ Relieve thirst, prevent dehydration, min. stimulation of GI tract

Full Liquid ◦ Turn to liquid at body tem, such as ice cream◦ GI disturbances ◦ Low in Fe, protein, and calories. High in cholesterol (amount of milk)◦ Ensure or Sustacal (oral supplement) not to replace a meal however.

Soft/Pureed Diet◦ Easily chewed and digested◦ Difficulty chewing and swallowing ◦ Low-fiber

Diet as tolerated◦ Appetite or ability to eat may change ◦ Changes according to situation ◦ Nurse makes judgment on if diet change.

Modification for disease ◦ DM: calorie-restricted◦ Cardiac: low sodium, cholesterol

Dysphagia◦ May aspirate food or fluids into lungs- causing pneumonia ◦ Stroke, cranial nerve dysfunction, radiotherapy in head and neck◦ Thin, nectar-like, honey-like, spoon-thick liquids

◦ Semisolid/solid foods: pureed, mechanically soft, mechanically altered, regular/general

Stimulating the Appetite Physical illness, unfamiliar or un palatable food, or other factors like discomfort and pain may

depress appetite. Decreased appetite usually is accompanied by decreased fluid intake which can cause fluid and

electrolyte imbalances. Improving Appetite:

◦ Provide familiar food that the person likes, relatives of clients may bring food, but must be educated about special diets.

◦ Select small portions to not discourage anorexic patients.◦ Avoid unpleasant or uncomfortable treatments before or after a meal.

▪ Allow patient to rest before eating after pt. ◦ Provide a tidy, clean environment free of unpleasant sights or odors. ◦ Encourage or provide oral hygiene before mealtime.

▪ Improved client's ability to taste. Cleanses palate. ◦ Relieve illness symptoms that depress appetite.

▪ Pain, fever, fatigue. ◦ Reduce psychological stress

▪ therapeutic communication. Providing Client Meals

◦ Position client◦ Clear overbed table◦ Make sure tray has client's name on it. ◦ Assist client if required.◦ Visually impaired patient's:

▪ describe foods in clockwise manner. ◦ After client is finished, observe how much is eaten/drank. ◦ Document any observations and or recommendations to enhance client eating. ◦ Whenever possible, let them feed themselves◦ Feeding aids (widened, foam, syringe, guards on plates)

Enteral Nutrition (EN or TEN) Through the GI tract Provided when client unable to inject foods or upper GI tract is impaired or transport to the

small intestine is interrupted.◦ Nutrients still able to be absorbed and metabolized.

Enteral Access Devices◦ Nasogastric or nasointestinal (nasoenteric) tubes or gastrostomy or jejunostomy tubes.◦ Nasogastric tube: inserted through one nostril down the nasopharynx and into the

alimentary tract. ▪ Indicated for clients who have adequate gastric emptying (short-term use)

Not advised for cleints without intact gag reflex.◦ Caution because might be placed in lungs without reflex.

May also be indicated to prevent:◦ nausea, vomiting, gastric distention after surgery.◦ Remove stomach contents for lab results. ◦ Wash the stomach in event of poison or overdose.

▪ Large-bore nasogastric tubes (larger than 12 Fr) Levin Tube: flexible rubber, single-lumen with holes near the tip. Fig 14A Salem sump tube: double lumen. Fig14B

◦ Larger lumen allows to deliver liquids or remove gastric content. ▪ When removing gastric content: smaller lumen (blue pigtail) allows for air to

prevent adhesion to the stomach wall. ▪ Usually smaller tubes (less than 12Fr) are used for enteral nutrition because they are

softer, and more flexible, and less irritating.

◦ Nasoenteric (nasointestinal) tube▪ Used for clients who are at risk for aspiration therefore bypassing stomach and going

straight into small intestine to prevent gastric contents from aspirating into lungs. Indicated for clients at risk for aspiration which are clients with:

◦ ALOC◦ Poor cough or gag reflexes◦ Inability to participate in the procedure◦ Restlessness or agitation

▪ Long tube that is at least 16in (for an adult) ▪ Procedure:

Place client in High Fowler's or in as high position as possible. Assess nares. Make sure stylet or guide-wire are secured in position to avoid damaging the GI

tract. If using a LARGE-BORE tube, place in warm water to allow tubing to be more

pliable and flexible. ◦ If more control of tube is needed, place tip of tube in ice water.

Measure from tip of nares → earlobe → xiphoid process to approximate distance from nares to stomach. ◦ Be sure to mark this length.

Insert the tube◦ Lubricate with water-soluble lubricant to prevent damage to lungs if accidentally

placed in lungs. ◦ Ask client to hyperextend the neck to reduce curvature of the nasopharyngeal

junction. ◦ Slight pressure and twisting may be required.

▪ Client may tear up, but it is a normal response. ▪ Once the tube meets resistance, withdraw it and relubricate and use the other

nostril. ◦ Once in the oropharynx, patient may have gag reflex.

▪ Ask client to tilt head forward and to slowly drink and swallow water.▪ Coordinate with client so that during the swallowing, pass the tube 2-4in

until the marked length is inserted, ▪ Once the tube meets resistance, withdraw it slightly, and inspect for any

coils. Ascertain proper tube placement

◦ Aspirate gastric contents: pH 1-5▪ ph 6+: indication of in lungs or in lower GI tract.

◦ Can also aspirate for bilirubin levels (1.5 in stomach, 0 in lungs)◦ If using small-bore wait until x-ray confirms placement before removing styler

or guide-wire. ◦ Auscultate placement by injecting 10mL-30mL of air into stomach.

Secure tube with tape and mark where edge of tube is. ◦ If Salem sump tube is used

▪ attach antireflux valve and position port above client's waste prevents gastric contents from flowing into the vent lumen.

Remove tube◦ Instill 50mL of air into tube to clear tube of residuals. ◦ Ask client to take deep breath and hold it.

▪ Closes glottis and prevents aspiration of any gastric contents during removal. ◦ Pinch tube to prevent contents from draining back inside client's throat. ◦ Place tube directly into bag to prevent transferring of microorganisms.

Gastrostomy and Jejunostomy Long-term nutritional support: 6-8 weeks Placed surgically or by laparoscopy through the abdominal wall. Percutaneous endoscopic gastrostomy (PEG) or Percutaneous endoscopic jejunostomy

(PEJ) ◦ created by visualizing the inside of the stomach and making a puncture through the

skin and tissues into the desired locating and inserting the PEG or PEJ catheter through the puncture.

◦ The opening around the tube is sutured tightly to prevent leakage. ▪ Care of this opening before it heals must be done with surgical asepsis.

◦ The catheters have external spacers and internal retention balloons to maintain placement.

◦ After 1 month, the tube can be removed and reinserted for each feeding. ▪ A low-profile skin-level tube can be placed permanently if so desired.

Testing Feeding Tube Placement ◦ Aspirate for GI secretions

▪ Caution: small-bore tubes are more likely to collapse during aspiration. ◦ Measure the pH of aspirated fluid

▪ Gastric aspirates: 1-4 (as high as 6 with antacids), ▪ Small intestine aspirates: pH equal to or higher than 6▪ Respiratory: 7 or higher ▪ Special considerations:

if pH readings are unexpected, a radiographic confirmation of tube needs to be considered especially for clients with diminished cough and gag reflexes.

◦ Auscultate the epigastrium while injection 5-20 mL of air. ◦ Confirm length of tube insertion with the insertion mark.

Enteral Feedings ◦ Standard: protein, fat, carbs, minerals, vitamins◦ Intermittent: 300-500 mL couple times/day over 30 min.◦ Bolus: syringe used to deliver formula ◦ Continuous: over 24-hours, infusion pump (kangaroo), essential in small-bore tubes or when

gravity flow is insufficient to instill the feeding. ◦ Cyclic: nocturnal feedings use higher infusion rates, allow client to attempt eating during

the day Caution: monitor fluid status and circulating volume

◦ Open systems▪ cans/ powdered formula w/ sterile h2o▪ no more than 8-12 hrs▪ bag and tubing replaced every 24 hrs.

◦ Closed systems: ▪ prefilled container, can hang for 48 hrs. if sterile

◦ Refeeding syndrome: shift in fluids and electrolyte after length period of malnutrition/starvation▪ during malnutrition the body starts making glucose from protein stores

when nutrition is suddenly present, fluid and electrolyte shift occurs. Persons at risk of refeeding syndrome:

◦ alcoholics, anorexics, massive weight loss, cancer clients receiving chemotherapy. ▪ Prevention:

Nursing history Lab tests: albumin, prealbumin, serum potassium, Ca, P, Mg.

▪ For clients “at risk” best to taper up nutrition starting at 25%. ◦ Start post-op w/o need to wait for flatus or bm (check for bowel sounds)

Before Administering a Tube Feeding Assessment Allergies Bowel sounds before each feeding

◦ q4-8h for continuous feedings Correct placement Presence of regurgitation and feelings of fullness after feedings

◦ may indicate delayed gastric emptying, need to decrease quantity or rate of feeding, or high fat content of formula causing fullness.

Dumping syndrome: nausea, vomiting, diarrhea, cramps, pallor, sweating, heart palpitations, increased pulse rate, and fainting after a feeding. ◦ Jejunostomy clients may experience these .

▪ Caused by sudden distention of jejunum which causes a rush of fluid from the vascular system to the intestine.

Abdominal distention Diarrhea, constipation, or flatulence.

◦ Hypertonic or concentrated ingredients may cause diarrhea or flatulence. Urine for sugar and acetone Hematocrit and Urine specific gravity Serum BUN and Na levels

Administering a Tube Feeding Assess tube placement

◦ check pH◦ allow 1 hr to pass before testing pH if the client has received a medication ◦ use a pH meter rather than a pH paper if client is on a continuous feeding.

Assess residual feeding contents ◦ if in the stomach

▪ aspirate all contents and measure all contents to evaluate the absorption of the

last feeding and whether undigested formula is still in the stomach▪ if 100mL (or more than 50%) is aspirated check with charge nurse regarding

hospital policy. ▪ If on continuous, check gastric residual q4-6h.

Administer feeding◦ check expiration date first◦ warm the feeding to room temperature because cold feeding may cause abdominal

cramps.◦ In an open system: clean the top of the container with alcohol before opening it.

If another bottle is not immediately hung, flush the feeding tube before the formula has run through the tubing.◦ Flushing prevents tube blockage◦ Be sure to add water before the solution has drained from the neck of the syringe or

from the tubing set.▪ Prevents instillation of air into the stomach or intestine.

Clamp feeding tube before all water is instill to prevent air from entering tube.

Open System Feeding Bag:◦ Apply label: date, time, initials◦ Hang bag 12in above point of insertion to ensure formula runs at safe rate into

stomach or intestine. ◦ Clamp the tubing and add the formula.◦ Open the clamp allow formula to run through the tubing then reclamp.

▪ This displaces air in the tubing to prevent excess air in the client's GI tract. ◦ Attach bag to feeding tube then regulate the drip if not placed on a pump.

Syringe (open system)◦ Remove plunger from syringe and connect syringe to clamped NG tube.◦ Add feeding to syringe barrel.

▪ Raise or lower syringe to adjust the flow as needed. ▪ Pinch or clamp tubing to stop flow for a minute if the client experience

discomfort. Closed System

◦ Hang container 12in above insertion point into the client for ensure formula runs at safe rate into stomach or intestine.

◦ Squeeze drip chamber until 1/3-1/2 capacity. ◦ Open tubing clamp, run formula, reclamp.◦ Attach feeding set tubing to feeding tube and regulate drip rate.

Continuous-Drip Feeding◦ Clamp tube q4-6h or hospital policy◦ Aspirate and measure gastric contents◦ Flush tubing with water. ◦ Withold feeding if 75-100mL of feeding is aspirated. ◦ To prevent spoilage or baceterial contamination, do not allow feeding solution to

hang longer than 4-8hrs. ◦ Follow hospital policy on how frequently to change feeding bag and tubing.

▪ Preferably q24h.

Administering Gastrostomy or Jejunostomy Feeding Insert a feeding tube if not already in place. Determine location and patency of tube.

◦ For continuous: check q4-6h and hold feedings according to hospital policy. Remove plunger and flush with 15ml-30ml of water. Administer feeding:

◦ hold barrel 3-6in above ostomy opening. ◦ Just before all formula has run out, add 30mL of water to flush and maintain patency.

Safely remove tubing if necessary Assess peristomal skin.

◦ Any nursing interventions needed regarding peristomal skin care.

Managing clogged tubes◦ Prevent: 30 mL before, between and after ◦ Reposition pt. to straighten kink◦ Alternately flush and aspirate w/ h2o

▪ can also flush with: meat tenderizer. ▪ Commercial de-clogging kits contain acids, buffers, antibacterial agents, enzymes, and

metal inhibitors. ◦ Do not add medications to formula or to each other

▪ can cause precipitate that clogs tube .

Parenteral Nutrition (TPN)◦ IV infusion: dextrose, h2o, fat, proteins, electrolytes, vitamins, trace elements◦ yellow◦ Hypertonic- into high-flow central veins diluted by blood ◦ Indicated for: Severe malnutrition, nitrogen imbalance, organ failures, metastatic cancer◦ Infection control, risk for fluid/electrolyte/glucose imbalance ◦ 1 L= 1000 mL of 5% dextrose = less than 200 cal◦ Prevent hyperglycemia/hypoglycemia – taper on/ off◦ Dextrose bypassing the GI, so give insulin (check glucose Q6h)◦ PPN

▪ Prevention deficits▪ Smaller peripheral veins- less concentrated solution ▪ Can accommodate lipids▪ Phlebitis (vein inflammation)▪ Short-term, used to prevent nutritional deficits, not correct. ▪ Have separate, dedicated line diff. from med IV▪ White