Chapter 24 Nutritional Care and Support - s3.amazonaws.com · Chapter 24 Nutritional Care and Support Modified 2017 by T. Collins, ... Add soft foods to a full liquid diet ... Concepts,

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


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



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



Supporting Nutritional Intake

Factors Impeding Nutritional Intake:

Anxiety

Pain

Fatigue

Anorexia nervosa (lack of appetite)

Nausea and vomiting

Disease and illness



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



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



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



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.



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



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)



Therapeutic Diets NPO: nothing to eat or drink

Includes tube feedings

Regular

No restrictions

Consider cultural/ethnic/religious affiliations



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



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



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



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.



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



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



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.



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



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



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



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



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



Physical Symptoms of Anorexia Nervosa

Brittle nails and hair

Amenorrhea

Severe constipation

Lethargy or fatigue

Below normal vital signs

Muscle weakness, muscle wasting

Anemia



Physical Symptoms

of Anorexia Nervosa



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



Physical Symptoms of

Bulimia



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



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



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



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



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.



Insertion, Irrigating, Removal of NG Tube

See Skill 24-3 pg. 528-531 in textbook



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



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



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



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

https://www.bing.com/videos/search?q=bolus+tube+feeding+demonstration&view=detail&mid=8B47E4D7C1BDE2257EED8B47E4D7C1BDE2257EED&FORM=VIRE





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



Complications Associated with Tube Feedings

Clogged tubes

Aspiration

Electrolyte imbalance

Hyperglycemia

Severe diarrhea

Dislocation



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



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



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



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



Monitoring Nutrition Status Daily weights

Electrolyte levels

Prealbumin, albumin, and total protein

Glucose level



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



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?



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?

Documents

Chapter 24 Nutritional Care and Support - s3.amazonaws.com · Chapter 24 Nutritional Care and Support Modified 2017 by T. Collins, ... Add soft foods to a full liquid diet ... Concepts,