Chapter 24. Nutritional Care and Support. Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition

Transcription

1 Chapter 24 Nutritional Care and Support Modified 2017 by T. Collins, MSN CMSRN

2 Terms Dysphagia: Difficulty swallowing Gastric decompression: The process of reducing the pressure within the stomach by emptying it of its contents, including ingested food and liquids, gastric juices, and gas Hemoglobin A 1C (Hb A 1C ): A test that monitors the long-term glucose level of the patient over the previous 90 days

3 Terms (cont.) Enteral nutrition: Delivers nutrition via the GI tract Parenteral nutrition: Nutrition administered directly into the bloodstream (IV), bypassing the GI tract Total parenteral nutrition (TPN): Hypertonic, nutritionally complete solution delivered via a largediameter central vein Partial parenteral nutrition (PPN): For patients who are able to meet some of their nutritional needs orally, but require additional calories or nutrients for a limited time due to illness

4 Supporting Nutritional Intake Factors Impeding Nutritional Intake: Anxiety Pain Fatigue Anorexia nervosa (lack of appetite) Nausea and vomiting Disease and illness

5 Assessments Nutritional Assessments Identify specific allergies Identify special diets at home and dietary preferences Note cultural or ethnic requirements or restrictions Assess physical capabilities and the need for assistance Assess medications that might affect diet

6 Mealtime Preparation Interventions: Remove odors Prepare the environment (clean the over-bed table!) Position the patient Ensure patient comfort (offer toilet) Wash your hands and the patient s face and hands Prepare the tray and open containers Assist the patient to eat

7 True/False Questions Assisting a patient with meals is a task that can be delegated to unlicensed assistive personnel (UAPs) or nursing assistants. A. True B. False

8 A. True Answer Assisting a patient with meals is a task that can be delegated to unlicensed assistive personnel (UAPs) or nursing assistants. However, before delegating the task, make certain that the UAP understands the patient s ethnic and cultural considerations related to different foods, nutrition, and mealtime.

9 Monitoring Intake/Output Intake Fluids taken by mouth, administered via IV, or administered per enteral or parenteral feedings Avg fluid intake = /Q24hrs Solids measured in percentages Liquids measured in milliliters (ml) Output All bodily fluids that are lost, including urine, emesis, liquid stool, blood, suctioned gastric contents, and drainage from drainage devices

10 Supporting Patients With Special Nutritional Needs Food Allergies vs. Food Intolerances: Food allergy A reaction by the patient s immune system to a food protein that causes a response by the immune system Common: Peanuts, Wheat, Dairy products, Eggs Anaphylaxis reaction-life threatening emergency Food intolerance Not an allergic reaction; it is an adverse reaction to a food without activation of the immune response Tyramines (aged cheese and wine) and metabolic disorders (gluten and lactose intolerances)

11 Therapeutic Diets NPO: nothing to eat or drink Includes tube feedings Regular No restrictions Consider cultural/ethnic/religious affiliations

12 Diets Modified for Consistency Clear liquid: Water, broth, and tea without milk Provides hydration with inadequate calorie, vitamins, protein, fat intake GI dz, postop patients Full liquid: Add opaque liquids to a clear diet Provides hydration with limited nutrients GI dz, postop patients Mechanical soft: Add soft foods to a full liquid diet Low in fiber and increases risk of constipation Jaw/chewing problems, unfit dentures Pureed diet: Any food processed in blender See Table 24-1

13 Diets Modified for Disease Diabetic Calorie-restricted Sodium-restricted Fat-restricted Fiber-restricted Renal Protein-restricted High-calorie, high-protein Antigen avoidance 5 to 6 small, frequent feedings

14 Multiple Choice Question A nurse is caring for a patient with an inflamed gallbladder. What type of diet would be prescribed for this patient? A. Fat-restricted B. Fiber restricted C. Protein-restricted D. High-calorie, high-protein

15 A. Fat restricted Answer Rationale: A fat-restricted diet is used for patients who are experiencing problems with fat malabsorption; for example, those with a disorder affecting the gallbladder, liver, lymphatic system, pancreas, or intestines.

16 Evaluation: Nursing Responsibilities Monitoring the diet type Percentage eaten Offering options if patient does not like/eat what is served- Identify why if not eaten Whether patient tolerated the meal

17 True/False Question The 2013 American Diabetic Association guidelines state that a range of 70 to 130 mg/dl before meals is acceptable for existing diabetics. A. True B. False

18 A. True Answer Rationale: The 2013 American Diabetic Association guidelines state that a range of 70 to 130 mg/dl before meals is acceptable for existing diabetics. Blood glucose should remain within a prescribed range established by the patient s physician.

19 Monitor FSBS Diabetic Patients Monitor Hb A 1C Monitor the percentage of meals eaten Monitor for S&Sx of hypoglycemia and hyperglycemia Treatment of low and high glucose

20 Diabetic Signs and Symptoms Hypoglycemia: Nervousness, shakiness, nausea, headache, irritability, clamminess, hunger, weakness, fatigue, low FSBS, confusion, seizures, coma Hyperglycemia: Hot, dry skin; flushed; increased thirst; dry mouth; headache; frequent urination; elevated FSBS; confusion; coma; death

21 Treating Abnormal Glucose Levels Hypoglycemia: Verify with FSBS, give a small glass of juice or 8 oz. of low-fat milk; mealtime not within a few minutes give additional snack such as cheese or peanut butter with a slice of whole wheat bread; recheck FSBS within 15 minutes; if critically low, give D50W IV Hyperglycemia: Insulin

22 Patient Teaching for Patients with Diabetes Eat a well-balanced diet Know the difference between simple and complex carbohydrates; reduce simple carbohydrate intake on a daily basis; a rare exception to this rule is acceptable Eat three meals and an evening snack daily Do not skip meals Increase fiber intake Reduce fat intake Lose weight if overweight

23 Eating Disorders Anorexia nervosa Characterized by an excessive leanness or wasting of the body, known as emaciation Relentless self-starvation in an effort to reduce the body weight to below normal Bulimia Binge eating frequently accompanied by purging, excessive exercise, fasting, or overuse of laxatives

24 Physical Symptoms of Anorexia Nervosa Brittle nails and hair Amenorrhea Severe constipation Lethargy or fatigue Below normal vital signs Muscle weakness, muscle wasting Anemia

25 Physical Symptoms of Anorexia Nervosa

26 Physical Symptoms of Bulimia Chronic soreness of the throat due to retching and exposure to gastric acid during vomiting Diarrhea from laxative abuse Increasing dental decay from gastric acid Indigestion Regurgitation of gastric fluids into the esophagus (gastric reflux) Dehydration

27 Physical Symptoms of Bulimia

28 Food-Drug Interactions Drug effects on: Food intake GI distress; drowsiness; confusion; weight gain or loss Absorption Ex. Antibiotics, narcotics, sedatives, steroids GI distress; decreased drug absorption Metabolism Ex. ASA, antineoplastics, increased gastric motility, high fiber diets Decreased and increased metabolism Excretion Ex. Anticonvulsants, anticoagulants Increased risk for toxicity Ex. Increased electrolyte imbalances

29 Some Specific Drugs INH: Increases excretion of Vitamin B6; give B6 Chemotherapy: Cause anorexia and N/V; give antiemetics Steroids: Cause weight gain, and glucose elevation and moon face; monitor FSBS, Warfarin: teach patients to avoid foods with Vitamin K Lasix: Depletes K+; monitor labs Lithium: Closely related to Na+ levels; monitor labs

30 Purposes: Enteral Tubes Decompress the stomach: postoperatively, following abdominal injury, intestinal obstruction Provide nutritional support or medication administration Collect a specimen of stomach contents for diagnostic assessment of the GI tract

31 Types of Enteral Tubes Nasogastric tubes(ng) Short term use only (10-14 days) Double lumen Salem sump tube a.k.a Nasogastric tube Single lumen Levine tube Measured in French Nasointestinal tube (NI) Used with GERD, decreased or no gag reflex Dobhoff Weighted on the tip Measured in French

32 Gastric Decompression What is gastric decompression? It is the process of reducing the pressure within the stomach by emptying it of its contents, including ingested food and liquids, gastric juices, and gas.

33 Insertion, Irrigating, Removal of NG Tube See Skill 24-3 pg in textbook

34 Nursing Responsibilities for NG Tube Suction Assess tube every 2 to 4 hours for patency Irrigate a clogged tube according to physician s instructions Monitor vacuum source setting Assess tubing connections and color, amount, and consistency of gastric drainage Assess the positioning of tubing Auscultate bowel sounds every 4 hours

35 Nursing Responsibilities for NG Tube to Suction (cont.) Assess the abdomen for distention Assess the patient for adverse effects every 2 hours Assess for passage of rectal flatus Provide mouth care every 2 hours and provide ice chips if not contraindicated Monitor I/O to prevent fluid deficit or overload Monitor serum potassium level for hypokalemia

36 Enteral Nutrition(via GI tract) Percutaneous Endoscopic Gastrostomy (PEG) tube Jejunostomy (J-tube) Nasogastric tube (NG) Nasointestinal tube (NI) See Figure 24-7 page 412

37 Enteral Feeding Methods Bolus feedings Intermittent feedings Equal portions administered as set intervals around the clock (4-6 times daily) Delivered by gravity via a bolus or drip set, feeding pump Maintain at room temperature Elevated the HOB degrees during feeding and one hr after Check residual before each feeding Caution: Air entering the tube causing GI distress. Risks: Aspiration, diarrhea, elevated glucose Continuous infusion feedings Continuous over an 8-24hr period, increasing to target rate for better tolerance and nutrient absorption Keep HOB elevated at 30 degrees Risks: Aspiration, diarrhea, elevated glucose

38 Enteral Feeding Nursing Care Check tube placement before each feeding Check residual volume before each feeding Elevate the HOB degrees Maintain tube patency Flushing q4hrs Assess bowel sounds Monitor I/O, ensuring balance Monitor weight, noting losses Monitor for diarrhea/constipation PEGs & J-tubes: Requires daily insertion-site care

39 Complications Associated with Tube Feedings Clogged tubes Aspiration Electrolyte imbalance Hyperglycemia Severe diarrhea Dislocation

40 Parenteral PPN & TPN(IV ROUTE) Partial parenteral nutrition (PPN) Administered through a peripheral intravenous central catheter (PICC) inserted into a smaller peripheral vein to meet nutrition needs not met by mouth intake alone Dz=short bowel syndrome, malabsorption syndrome Total parenteral nutrition (TPN) Administered through a central venous catheter (CVC) placed in a larger central vein on chest or neck Dz=burns, trauma, sepsis, cancer, GI disorders

41 PPN vs. TPN Partial parenteral nutrition (PPN) Administered through a peripheral intravenous central catheter (PICC) inserted into a smaller peripheral vein Total parenteral nutrition (TPN) Administered through a central venous catheter (CVC) placed in a larger central vein Core differences are the vessel selected to receive the nutrition and the concentration of solution infused Titrate slowly at KVO and increased at 25ml/hr increments to reach target rate to prevent hyperglycemia, coma or death Monitor labs daily Aseptic technique required

42 Parenteral Feeding Nursing Care Check tube placement before each feeding Check residual volume before each feeding Elevate the HOB degrees Maintain tube patency Flushing q4hrs Assess bowel sounds Monitor I/O, ensuring balance Monitor weight, noting losses Monitor for diarrhea/constipation Site care per RN or permitted LPN/LVNs if policy permitted

43 Parenteral Feeding Nursing Care cont d Review Box 24-5 page 517 Do not use and discard all unlabeled formula nd out-of-date formula Never add new formula to old Change the feeding bag and syringe every 24hrs

44 Monitoring Nutrition Status Daily weights Electrolyte levels Prealbumin, albumin, and total protein Glucose level

45 Information in the Connection Features Clinical Connection Knowledge Laboratory and Diagnostic Patient Teaching Anatomy and Physiology Real World Supervision/Delegation People and Places Post Conference

46 Information in the Safety Features Why are the particular safety features so important that they are highlighted as safety issues? What could happen if those safety guidelines are not followed?

47 Information in the Skills Procedures Review the steps of each of the skills procedures. Make sure you understand why the steps are important. What could happen if each of the steps are not followed or are followed out of order?