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TRANSCRIPT
Copyright © 2008 Lippincott Williams & Wilkins.
Chapter 36Gastrointestinal Intubation and Special Nutritional Modalities
Chapter 36Gastrointestinal Intubation and Special Nutritional Modalities
Copyright © 2008 Lippincott Williams & Wilkins.
Purposes of GI IntubationPurposes of GI Intubation
• Decompress the stomach
• Lavage the stomach
• Diagnose GI disorders
• Administer medications and feeding
• Treat an obstruction
• Compress a bleeding site
• Aspirate gastric contents for analysis
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Types of TubesTypes of Tubes
• Gastric tubes
– Levin
– Sump
• Enteric tubes
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Nursing Care of the Patient with a Nasogastric or Nasoenteric TubeNursing Care of the Patient with a Nasogastric or Nasoenteric Tube
• Patient teaching and preparation
• Tube insertion
• Confirming placement
• Securing the tube
• Monitoring the patient
• Maintaining tube function
• Oral and nasal care
• Monitoring, preventing, and managing complications
• Tube removal
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Measuring for Nasogastric Tube Insertion Measuring for Nasogastric Tube Insertion
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Purposes and Advantages of Enteral FeedingPurposes and Advantages of Enteral Feeding
• Meets nutritional requirements when oral intake is inadequate or not possible, and the GI tract is functioning
• Advantages:
– Safe and cost-effective
– Preserves GI integrity
– Preserves the normal sequence of intestinal and hepatic metabolism
– Maintains fat metabolism and lipoprotein synthesis
– Maintains normal insulin and glucagon ratios
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Tube Feeding Administration MethodsTube Feeding Administration Methods
• Tubes
– Nasogastric or nasoenteral tubes
– Gastrostomy or jejunostomy tubes for long-term feeding
• Methods
– Intermittent bolus feedings
– Intermittent gravity drip
– Continuous infusion
– Cyclic feeding
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Bolus Gastrostomy Feeding by GravityBolus Gastrostomy Feeding by Gravity
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Nasoenteric Feeding by Continuous Controlled PumpNasoenteric Feeding by Continuous Controlled Pump
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Nursing Process: The Care of the Patient Receiving an Enteral Feeding: AssessmentNursing Process: The Care of the Patient
Receiving an Enteral Feeding: Assessment
• Nutritional status and nutritional assessment
• Factors or illnesses that increase metabolic needs
• Hydration and fluid needs
• Digestive tract function
• Renal function and electrolyte status
• Medications that affect nutrition intake and function of the GI tract
• Compare the dietary prescription to the patient’s needs.
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Nursing Process: The Care of the Patient Receiving an Enteral Feeding: Diagnosis Nursing Process: The Care of the Patient Receiving an Enteral Feeding: Diagnosis
• Imbalanced nutrition
• Risk for diarrhea
• Risk for ineffective airway clearance
• Risk for deficient fluid
• Risk for ineffective coping
• Risk for ineffective therapeutic regimen management
• Deficient knowledge
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Collaborative Problems/Potential Complications (See Table 36-3)Collaborative Problems/Potential Complications (See Table 36-3)
• Diarrhea
• Nausea and vomiting
• Gas/bloating/cramping
• Dumping syndrome
• Aspiration pneumonia
• Tube displacement
• Tube obstruction
• Nasopharyngeal irritation
• Hyperglycemia
• Dehydration and azotemia
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Nursing Process: The Care of the Patient Receiving an Enteral Feeding: PlanningNursing Process: The Care of the Patient Receiving an Enteral Feeding: Planning
• Major goals may include nutritional balance, normal bowel elimination pattern, reduced risk of aspiration, adequate hydration, individual coping, knowledge of and skill in self-care, and prevention of complications.
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Maintaining Nutrition Balance and Tube FunctionMaintaining Nutrition Balance and Tube Function
• Administer feeding at prescribed rate and method and according to patient tolerance.
• Measure residual prior to intermittent feedings and every 4-8 hours during continuous feedings.
• Administer water before and after each medication and each feeding, before and after checking residual, every 4 to 6 hours, and whenever the tube feeding is discontinued or interrupted.
• Do not mix medications with feedings.
• Use a 30-mL or larger syringe.
• Maintain delivery system as required. To avoid bacterial contamination, do not hang more than 4 hours of feeding in an open system.
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Maintaining Normal Bowel EliminationMaintaining Normal Bowel Elimination
• Selection of TF formula: consider fiber, osmolality, and fluid content
• Prevent contamination of TF: maintain closed system, do not hang more than 4 hours of TF in an open system.
• Maintain proper nutritional intake.
• Assess for reason for diarrhea and obtain treatment as needed.
• Administer TF slowly to prevent dumping syndrome (See Chart 36-2).
• Avoid cold TF.
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Reduce Risk for AspirationReduce Risk for Aspiration
• Elevate HOB at least 30-45 degrees during and for at least 1 hour after feedings.
• Monitor residual volumes.
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Other InterventionsOther Interventions
• Maintain hydration by supplying additional water and assessing for signs of dehydration.
• Promote coping by support and encouragement; encourage self-care and activities.
• Patient teaching
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Gastrostomy TubesGastrostomy Tubes
• Types of tubes:
– Stamm
– Janeway
– PEG
– Low-profile gastrostomy device (LPGD)
• Insertion of the PEG tube
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Nursing Process: The Care of the Patient With a Gastrostomy: AssessmentNursing Process: The Care of the Patient With a Gastrostomy: Assessment
• Patient knowledge and ability to learn
• Self-care ability and support
• Skin condition
• Nutrition and fluid status
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Nursing Process: The Care of the Patient With a Gastrostomy: DiagnosisNursing Process: The Care of the Patient With a Gastrostomy: Diagnosis
• Imbalanced nutrition
• Risk of infection
• Risk for impaired skin integrity
• Ineffective coping
• Disturbed body image
• Risk for ineffective therapeutic regimen management
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Collaborative Problems/Potential ComplicationsCollaborative Problems/Potential Complications
• Wound infection
• GI bleeding
• Premature removal of tube
• Aspiration
• Constipation
• Diarrhea
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Nursing Process: The Care of the Patient With a Gastrostomy: PlanningNursing Process: The Care of the Patient With a Gastrostomy: Planning
• Major goals include attaining an optimal level of nutrition, preventing infection, maintaining skin integrity, enhancing coping skills, adjusting to changes in body image, acquiring knowledge of and skill in self-care, and preventing complications.
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Tube Care and Preventing InfectionTube Care and Preventing Infection
• Proper use of dressing
• Skin care around the tube
• Manipulation of the stabilizing disk to prevent skin breakdown
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Parenteral NutritionParenteral Nutrition
• A method to provide nutrients to the body by an IV route
• A complex mixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water is administered in a single container.
• The goals of parenteral nutrition are to improve nutritional status and to attain a positive nitrogen status.
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Indications for Parenteral Nutrition Indications for Parenteral Nutrition
• Intake is insufficient to maintain anabolic state.
• Ability to ingest food orally or by tube is impaired.
• Patient is not interested in ingesting or is unwilling to ingest adequate nutrients.
• The underlying medical condition precludes oral or tube feeding.
• Preoperative and postoperative nutritional needs are prolonged.
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Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: Assessment
Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: Assessment• Assist in identifying patients who are candidates for PN
• Nutrition status
• Hydration status
• Electrolytes
• Signs and symptoms of hypoglycemia/hyperglycemia
– Monitor blood glucose levels.
• Assess for potential complications
– VS including temperature every 4 hours or by protocol
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Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: DiagnosisNursing Process: The Care of the Patient Receiving Parenteral Nutrition: Diagnosis
• Imbalanced nutrition
• Risk for infection
• Risk for excess or deficient fluid
• Risk for immobility
• Risk of ineffective therapeutic regimen
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Collaborative Problems and Potential ComplicationsCollaborative Problems and Potential Complications
• Pneumothorax
• Clotted or displaced catheter
• Sepsis
• Hyperglycemia
• Rebound hypoglycemia
• Fluid overload
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Nursing Process: The Care of the Patient Receiving Parenteral Nutrition: PlanningNursing Process: The Care of the Patient Receiving Parenteral Nutrition: Planning
• Major goals may include attaining an optimal level of nutrition, absence of infection, adequate fluid volume, optimal level of activity, knowledge of self-care, and absence of complications.
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Prevention of InfectionPrevention of Infection
• Appropriate catheter and IV site care
• Strict sterile technique for dressing changes
• Wear mask when changing the dressing.
• Assess insertion site.
• Assess for indicators of infection.
• Proper IV and tubing care
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Maintaining Fluid BalanceMaintaining Fluid Balance
• Use infusion pump. Flow rate should not be increased or decreased rapidly. If fluid runs out, hang 10% dextrose solution.
• Monitor indicators of fluid balance and electrolyte levels.
• I&O
• Weights
• Monitor blood glucose levels.
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Patient Teaching (See Charts 36-5 and 36-6)Patient Teaching (See Charts 36-5 and 36-6)
• Goals and purpose
• Components of PN
• Emergency contact numbers
• Demonstrate use of equipment and how to handle and hang the IV.
• Demonstrate dressing changes.
• Demonstrate how to flush or heparinize the catheter.
• Potential complications and actions to take