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Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015 Copyright F.A. Davis © 2015
Chapter 24 Nutritional Care and Support Modified 2017 by T. Collins, MSN CMSRN
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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 A1C (Hb A1C): A test that monitors the long-term glucose level of the patient over the previous 90 days
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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 large-diameter 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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Supporting Nutritional Intake
Factors Impeding Nutritional Intake:
Anxiety
Pain
Fatigue
Anorexia nervosa (lack of appetite)
Nausea and vomiting
Disease and illness
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Answer
A. True
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.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Monitoring Intake/Output Intake
Fluids taken by mouth, administered via IV, or administered per enteral or parenteral feedings
Avg fluid intake = 1500-2500/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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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)
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Therapeutic Diets NPO: nothing to eat or drink
Includes tube feedings
Regular
No restrictions
Consider cultural/ethnic/religious affiliations
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Answer
A. Fat restricted
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.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Nursing Responsibilities
Evaluation:
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Answer
A. True
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.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Diabetic Patients
Monitor FSBS
Monitor Hb A1C
Monitor the percentage of meals eaten
Monitor for S&Sx of hypoglycemia and hyperglycemia
Treatment of low and high glucose
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Physical Symptoms of Anorexia Nervosa
Brittle nails and hair
Amenorrhea
Severe constipation
Lethargy or fatigue
Below normal vital signs
Muscle weakness, muscle wasting
Anemia
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Physical Symptoms
of Anorexia Nervosa
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Physical Symptoms of
Bulimia
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Food-Drug Interactions Drug effects on:
Food intake
GI distress; drowsiness; confusion; weight gain or loss
Ex. Antibiotics, narcotics, sedatives, steroids
Absorption
GI distress; decreased drug absorption
Ex. ASA, antineoplastics, increased gastric motility, high fiber diets
Metabolism
Decreased and increased metabolism
Ex. Anticonvulsants, anticoagulants
Excretion
Increased risk for toxicity
Ex. Increased electrolyte imbalances
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Enteral Tubes
Purposes:
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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.
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Insertion, Irrigating, Removal of NG Tube
See Skill 24-3 pg. 528-531 in textbook
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Enteral Feeding Methods Bolus feedings https://www.bing.com/videos/search?q=bolus+tube+feeding+demonstration&view=detail&mid=8B47E4D7C1BDE2257EED8B47E4D7C1BDE2257EED&FORM=VIRE
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 30-45 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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Enteral Feeding Nursing Care Check tube placement before each feeding
Check residual volume before each feeding
Elevate the HOB
30-35 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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Complications Associated with Tube Feedings
Clogged tubes
Aspiration
Electrolyte imbalance
Hyperglycemia
Severe diarrhea
Dislocation
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Parenteral Feeding Nursing Care Check tube placement before each feeding
Check residual volume before each feeding
Elevate the HOB
30-35 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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
Monitoring Nutrition Status Daily weights
Electrolyte levels
Prealbumin, albumin, and total protein
Glucose level
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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?
Fundamentals of Nursing Care Concepts, Connections, & Skills, Second Edition
Copyright F.A. Davis © 2015
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?