NUTRITIONAL THERAPY AND ASSISTED FEEDING

Chapter 27

Objectives

1) Identify the nurse’s role related to nutritional therapy and special dietary needs.

2) Compare and contrast a full liquid with a clear liquid diet.

3) Explain the different dietary modification levels: puréed, mechanically altered, advanced, and regular.

4) Describe health issues related to nutrition.

5) List disease processes that may benefit from nutritional therapy.

6) Verbalize the rational for assisted feedings and tube feedings

7) List the steps for the procedure to insert, irrigate, and remove a nasogastric tube

8) Discuss the procedure for tube feedings

9) Identify medical rationale and nursing care for a patient receiving peripheral parenteral nutrition (PPN) and total parenteral nutrition (TPN)

10) Understand the possible complications associated with modified diets, tube feedings, PPN, and TPN

Skills & Steps

Skills

■ Assisting a Patient with Feeding

■ Inserting a Nasogastric Tube

■ Using a Feeding Pump

■ Administering a Nasogastric, Duodenal, or Percutaneous Endoscopic Gastrostomy Tube Feeding

Steps

■ Nasogastric Tube Irrigation

■ Nasogastric Tube Removal

Goals of Nutritional Therapy ■ The goals of nutritional therapy are to treat and manage disease, prevent complications,

and restore or maintain health through appropriate diet

■ Specific diet for each patient is prescribed on the PCP order

– Some patients may have diets without restrictions that are similar to meals eaten at home

– Other patients, nutritional therapy is a significant factor in their medical treatment

■ You can assist patients in meeting their nutritional goals by completing thorough nutritional data collection

■ Monitor the patient’s food and fluid intake and document the response to therapy

– Weight gain or loss, percentage of meals eaten, and ability to tolerate the diet should be included in the documentation

■ Patients who may need assistance with food and fluid intake include those who have paralysis of the arms, visual impairment, intravenous lines or other devices in their hand or arm, problems breathing or problems swallowing (dysphagia) or sever impairments or weakness

– You may delegate this task to the nursing assistant or a family member, if appropriate

■ Skill 27.1 – Assisting a Patient with Feeding

The Postoperative Patient ■ Patients scheduled for a surgical procedures may have special nutritional needs

– Ideally, the surgical patient should be well nourished preoperatively (before surgery) to facilitate postoperative (after surgery) healing and recovery

■ Preoperative patients usually placed on NPO (take no food or fluids by mouth) status for up to 12 hours before the procedure

– This practice decreases the risk of vomiting while under anesthesia, which could lead to aspiration of stomach contents ----- aspiration can result in serious respiratory complications

■ Always check with the surgeon on for exceptions to NPO orders

– These may include diabetic, cardiac, and / or any other medications (with a

“sip” of water) that ensure patient stability during surgery

■ Prior to giving anything by mouth (usually 4 hours) check that the patient is alert, bowel sounds are present and the swallow reflex is present

■ Encourage ice chips 4 hours before first meal

■ Postoperative patients progress from a clear liquid diet to a full liquid diet

■ Solid foods are added when the patient can tolerate them without nausea, vomiting or other abdominal discomfort

The Postoperative Patient

■ Clear liquids are started when the patient has a return of bowel sounds detected by

auscultation

– They primarily maintain fluid homeostasis and relieve thirst

– Goal is to introduce fluids that have low residue (remains after digestion) are digested, and have low risk of causing discomfort –abdominal distress, such as

vomiting and distention, can cause injury to surgical interventions

■ Foods that are clear fluids at room temperature (gelatin, popsicles) and liquids that are clear are included on the clear liquid diet

■ Clear liquid diets are used short term because the diet is deficient in most nutrients

■ Bouillon (broth) added to the diet provides small amounts of protein and some electrolytes

The Postoperative Patient

■ Full liquid diet may be used as a step between clear liquid and mechanical soft or regular diet

■ Full liquid is used following surgery, long term fasting, or for those with chewing or swallowing problems

■ Full liquid diets include all fluids, custards, ice cream, sherbet, puddings, and cooked refined cereals

■ Can be used for long term nutritional management because protein and other

essential nutrients, vitamins, and minerals are available from the foods allowed

■ Full liquid diet is, however, low in iron, vitamin A, vitamin B12, and thiamine; therefore, vitamin and mineral supplements must be provided for longer – term use

■ Foods allowed in clear liquid diets are compared in Box 27.1

The Postoperative Patient

■ Patients recovering from surgical procedures that involved manipulation of or surgical incisions onto the stomach or bowel may progress to a soft diet before attempting a general or regular diet

■ Soft diets are low in fiber, and foods are softened by cooking, mashing, or chopping

– Foods allowed on a soft diet include eggs; breads without seeds; boiled or mashed potatoes; soups; fruit; juices; tender cooked vegetables; meat that is stewed, boiled or ground; cooked cereals; mashed bananas; applesauce ; and milk products

– As condition progresses, the diet is advanced to general – this diet has no specific restrictions unless required because of patient’s specific disease process

Feeding and Eating Disorders ■ Feeding and eating disorders are compromised of categories of disorders that occur across the

life span

■ In adolescence and young adult hood, individuals can develop conditions related to dietary intake

– Diagnosed as mental health disorders such as anorexia nervosa, bulimia nervosa, and binge eating

■ Anorexia Nervosa is a psychological disorder characterized by restriction of caloric intake, a very low body weight for the developmental stage, a pathological fear of becoming fat, and a severe disturbance young in body image

– Prevalent among the adolescent and young women; however, adolescent and young men may also be affected

– They view themselves as obese despite being extremely underweight

– They restrict caloric intake and focus on moderate to vigorous physical activity

■ If not corrected, anorexia, nervosa can be fatal

■ Treatment is a combination of nutritional intervention, behavioral modification, and psychological counseling

■ Treatment goals are to plan and achieve a nutritious, healthy eating pattern and to attain a body weight that is at least 85% of expected weight for height

Feeding and Eating Disorders ■ Bulimia Nervosa is an eating disorder characterized by episodic binge eating,

followed by behaviors designed to prevent weight gain, including purging, fasting, using laxatives, and exercising excessively

■ Woman are aware of their problem and often feel ashamed of the behavior

■ Treatment is usually easier because of the awareness

– Psychological and nutritional counseling is necessary

– May include nutritional supplements and monitoring of patients after eating to ensure purging does not occur

■ Medical conditions such as esophageal and peptic ulcers, depressed gag reflex, and dental issues may accompany bulimia because of the gastric acid exposure during frequently induced vomiting

■ This condition may be treated with behavioral modification to stop these practices

Binge Eating Disorders

■ Binge eating defined as recurrent episodes of consuming significantly more food in a defined period of time than most people would eat under similar circumstances

■ One of the most common eating disorders however, it often goes underdiagnosed

■ Marked by feelings of lack of control

– Consumes food rather quickly and often do so when they are no hungry

■ Women are most often affected

■ Most individuals generally hide their habit as it is characterized by feelings of guilt, embarrassment, or disgust

■ Nursing interventions for patients with feeding and eating disorders include nutritional management, behavioral modification, patient education, and monitoring progress

– Should include principles of healthy weight gain maintenance, components of a healthy diet, and dangers of fasting, purging, and binging; and the availability of the diet and

need for modification of any aspect of the treatment plan

■ Clinical Cues

Obesity

■ Obesity – excessive accumulated fat – rates continue to rise, and it has become a national health threat

■ CDC estimates that about 34.9% or 78.6 million, of adult Americans are obese

■ Poor diet and limited physical activity are major factors contributing to the epidemic levels of overweight and obese Americans

■ Second leading cause of preventable deaths in the US

■ Many factors contribute to obesity, including genetics, environment, poor eating habits, lack

of knowledge about good nutrition, medications, body physiology, age, gender

■ Nutritional modifications and physical activity to manage obesity must be individualized and incorporate all factors relevant to the patient

■ Documented that obesity is responsible for putting people at risk for 30 chronic health conditions, including cardiovascular disease, stroke, diabetes, hypertension, gallbladder disease, kidney disease, arthritis and some forms of cancer

Obesity

■ Goal of obesity treatment is to improve health and quality of life

■ Long term success of weight management low

– Approximately 5% of obese people who reach their desired weight management goal can maintain their weight status over a 2-5 year period

■ To accomplish weight loss, the individual must expend more energy than is consumed through intake of calories

■ Physical activity is designed to match the patient’s ability is usually a component of weight management programs

■ Nutritional therapy depends on the patient’s degree of obesity

– Characterized as mild to extreme

■ Determined using the body mass index (BMI) chart

– Mathematical equation of height and weight

– May not be as reliable in individuals with very lean bodies or those who are pregnant or lactating

– Nutritional considerations

Obesity

■ Treatments include consultation and follow up with a health care provider, medically supervised special meal plans, medications (including appetite suppressants and nutrition absorption blockers) and surgical interventions

■ Effective nursing activities for weight reduction assistance include encouragement of low calorie diets, plant based or vegetarian diets, appropriate portion size activity recommendations and behavioral modification

■ Bariatric surgery, which reduces stomach size and/or reduces calorie and nutritional

absorption, is currently touted as the most effective treatment to provide long lasting weight loss for people with extreme obesity – however, there are serious potential complications, even death

■ Very low calorie diets (< 500 calories /day) are used only under close medical supervision because they can produce harmful complications

Pregnancy ■ Nutritional status before and during pregnancy can influence the health of the mother and

the fetus

■ Nutritional data collection and counseling are important throughout the pregnancy to reduce the risk of complications such as low birth weight infants, gestational diabetes and hyper induced hypertension

■ Factors to consider when counseling a pregnant woman include her nutritional status before pregnancy, her age, the number of prior pregnancies, and her BMI at the onset of

pregnancy

■ An increase in nutrients is needed for healthy growth of fetal and maternal tissues

■ Counseling should emphasize management of maternal weight gain and the taking of prenatal supplements as prescribed

Substance – Related and Addictive Disorders

■ Individuals who use alcohol, smoking, and other substances often present with nutritional deficits when entering health care facilities

■ Substance use interferes with food intake by decreasing appetite, decreasing financial resources for food, and substituting calories in alcohol for calories in food

■ Substance use may also lead to impaired absorption and reduce storage and use of nutrients along with increased metabolic needs

■ Thiamine deficiency is often present with alcohol use

■ Medical treatment usually includes fluid and electrolyte supplements; especially thiamine, and a high calorie, high carbohydrate diet

■ Liver damage is common in patients with substance use because of the increased stress of metabolizing excessive alcohol and other substances

– Dietary fat should be restricted if liver function is impaired

Cardiovascular Disease ■ Cardiovascular disease includes diseases of blood vessels, hypertension, myocardial infarction (loss of

blood supply to the heart muscle) and heart failure (pump failure of the right or left ventricle)

■ Nutritional therapy is focused on reduction of saturated and trans-fat, cholesterol, sodium intake, and red meats

■ Excessive saturated and trans-fat intake leads to develop of atherosclerosis (accumulation of fatty deposits on the walls of blood vessels)

– this process narrows the vessel diameter, resulting in decreased blood supply throughout the body and specifically to the major organs

– Narrow blood vessels increase the workload of the heart, resulting in hypertension as the heart attempts to circulate blood

■ The blood contains three types of cholesterol

– HDL (high density lipoprotein) known as “good cholesterol” tends to cleanse vessels of fatty deposits

– LDL (low density lipoprotein) increases fatty deposits on vessel walls

– VLDL (very low density lipoprotein) serves as a carrier for triglycerides in the blood (a type of fat linked to atherosclerosis and coronary artery disease) – therefore levels should be kept low

■ Consumption of trans-fat, also increases level of triglycerides

– Can also signal a risk for diabetes or poor control of diabetes

■ Red meats, eggs, and high fat diary products contain large amounts of saturated fat

■ Convenience foods, such as prepackaged or frozen foods, chips, and fast foods, usually have high levels of trans-fat

Cardiovascular Disease ■ Consumption of low fat dairy products, vegetable oils, poultry, and fish is desirable

to lower cholesterol levels.

■ Research suggest that concentrated sugars may play a greater role in the development of saturated fats

– Studies have linked a diet high in sugars to a 3-fold increase in death from cardiac disease with fructose and sucrose posing the greatest risk

■ Vitamin D may prevent cardiovascular disease, but 3 out of 4 Americans do not have adequate levels (30-40 ng/mL)

■ Several studies identified that calcium supplements with vitamin D decrease the inflammatory response, thereby decreasing the risk for cardiovascular disease – still food is the best source of calcium

■ Several studies identified that calcium supplements with vitamin D decrease the inflammatory response, thereby decreasing the risk of cardiovascular disease

Cardiovascular Disease

■ Control of dietary sodium is also therapeutic in prevention and management of cardiovascular disease

■ Large amounts of sodium cause fluid retention. Increased fluid volume in patients with heart failure increases the workload of the heart and results in increased respiratory distress and edema in the legs and feet

■ Increased fluid volume and edema can also lead to hypertension

■ Research shows diets low in sodium and high in fruits, vegetables, nuts, seeds, legumes,

and low low-fat dairy products – can lower blood pressure even in healthy people

■ Teach and encourage patients to read food and beverage labels for sodium content and avoid adding salt to foods during cooking

Diabetes Mellitus

■ Diabetes Mellitus is a disturbance of the metabolism of carbohydrates and other nutrients and the use of glucose by the body

■ Two main types of diabetes

– Type 1 diabetes (T1DM) occurs when the beta cells of the pancreas stop secreting insulin

■ Insulin is needed to transport glucose across the cell wall

■ Usually develops at an early age

– Type 2 diabetes (T2DM) accounts for 90% -95% of all cases of diabetes; occurs when glucose receptors on the cell membrane lose their sensitivity to insulin

■ Insulin is secreted in normal or excessive amounts; however, the receptor sites do not allow

most glucose to enter the cell

■ Although it used to appear primarily after age 40, type 2 diabetes is now appearing

frequently in younger people; even children

■ The goal of nutritional therapy for patients with diabetes is to control the amount of carbohydrates in the diet to maintain the blood glucose level at 70-110 mg/dL

Diabetes Mellitus

■ Patients with diabetes are at higher risk for cardiovascular disease, hypertension, kidney disease, blindness, and stroke.

■ The nurse should encourage patients with diabetes to monitor their blood glucose closely, especially the effect of carbohydrate intake on blood vessels

■ Instruct patients in ways to include favorite foods into the diet and remain within their individual dietary plan

– Develop the plan taking into consideration the type of diabetes, the patient’s activity level, and whether the patient is overweight ---every person with diabetes responds differently to carbohydrate intake

– A patient can monitor his response to particular carbohydrates by measuring the blood glucose 1 ½ to 2 hours after eating

■ A blood glucose < 180 mg/dL or below usually indicates an acceptable level following meals

■ Box 27.2 Dietary Strategies for Patients with Diabetes

HIV / AIDS

■ Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are associated with severe diarrhea, profound weight loss, and muscle wasting

– Some patients lose as much as 50% of their body weight because of the treatment,

multiple infections, loss of appetite, malignancies, and gastrointestinal disorders

– Nutritional therapy is directed toward replacing fluids and electrolytes, fostering weight gain, replacing muscle mass through protein intake, and maintaining the strength of the immune system

■ Calorie intake should be increased for patients with HIV/AIDS, with emphasis on protein intake

■ Infections, and impaired immune system, and medical treatment may result in painful lesions in the mouth and may be difficult to eat

– Offer milkshakes with added calories and supplements such as Ensure Plus or Boost Plus to provide calories and protein

– Fluids and electrolytes are best replaced orally, but per medical orders, may be replaced intravenously

HIV / AIDS

■ Dietary considerations include:

– Maintaining high calorie intake

– Increasing protein intake to maintain or increase muscle mass

– Offering bland, soft, or pureed foods when the mouth is painful

– Adding thickening agents to liquids if indicated by the swallowing evaluation

■ If thickening agents are used, assess for adequate hydration, because research has shown

they may lead to inadequate fluid intake

– Encouraging small, frequent meals

■ Table 27.3

Assisted Feeding

■ Patients who have high care needs, malnutrition, cardiovascular or nervous system disorders, or dementia may be unable to tolerate oral fluid and food intake

■ One in five older adults residing in long term care facilities may experience dysphagia (difficult swallowing)

– Some people may show common signs of swallowing problems such as coughing when drinking, drooling, or having food remaining in the mouth

■ More than half of patients who aspirate show no obvious signs or symptoms such as coughing

– The aspiration may cause a voice change or feeling of food being stuck in the throat

■ Liquids may be thickened to help prevent aspiration

■ Solids can be ordered at four different texture levels

– Level I – pureed ( pudding texture)

– Level II – mechanically altered (moist and minced to ¼ inch maximum)

– Level III – advanced (moist and bite sized; no hard or crunchy foods)

– Level IV – regular (all foods)

■ Some patients recover and advance to level IV, whereas others may progress in their aging or disease process and may no longer tolerate oral intake of any kind. Once this happens, a feeding tube can be considered

Nasogastric and Enteral Tubes■ There are several type of enteral tubes

– Tubes may be placed through the nose into the stomach (nasogastric tube - NG)

– Placed directly into the stomach (gastrostomy tube / percutaneous endoscopic gastrostomy tube – PEG)

– Placed into the intestine (jejunostomy or duodenal tubes)

■ When enteral (intestinally absorbed) nutrition is needed over an extended time, small bore feeding tubes (8 -10 Fr.) may be inserted

– Small bore tubes are soft, flexible tubes that must be inserted by a skilled person using a guidewire or stylet. Active patients may find the tube restrictive and inconvenient

■ Nursing care pf patients with NG tubes involves insertion, irrigation, administration of tube feeding, checks for placement, checks for residual volume, and removal of the tube

– Success in inserting the tube is more likely if the patient’s confidence is gained first

– Explain the procedure and its benefit to the patient before beginning insertion

– Proper placement of small-bore tubes must be verified by x-ray examination

■ A tube that is not correctly positioned or poor body position can cause aspiration

■ Elevate the head of the bed for 30 to 60 minutes after a feeding to ensure residual volume is not aspirated

Nasogastric and Enteral Tubes

■ QSEN Consideration: Safety

– Check Tube Placement and Residual Volume

■ Monitor NG tubes frequently

■ Irrigate the NG tube with 30 – 60 mL of sterile water solution to ensure it is patent

■ Count the amount used for irrigation as part of the recorded intake

■ Monitor for complications such as constipation, nausea, diarrhea, hyperglycemia, and electrolyte imbalances

■ When therapy is completed or the patient is able to tolerate oral feedings, remove the NG tube

■ Skill 27.2 – Inserting NG tube

■ Steps 27.1 – Nasogastric Tube Irrigation

Percutaneous Endoscopic Gastrostomy or Jejunostomy Tubes

■ A PEG or PEJ tube is used when a patient requires long-term nutritional support and cannot take oral nutrition

– The PEG/J tube has replaced surgical gastrostomy tube placement in most situations

– Tube placed is placed via endoscopy

– It allows patients more freedom of ambulation and allows the patient to administer his own feedings easily

– A PEG/J tube can be removed easily when it is no longer indicated

– Care of the PEG/J tube is similar to that of the NG tube

■ Check tube placement a least every shift and before feeding or administering medication

– Check the medical record for the placement measurements

– Measure the tube length from skin level to the end of the placement adapter; compare

the measurements indicate the tube has migrated outward

– If the tube becomes dislodged, notify the charge nurse and PCP

Feeding Tubes and Pumps■ Tube feedings can be continuous or intermittent

– continuous is effective for patients who cannot tolerate large amounts of fluid at one time

– intermittent is beneficial for patients who are able to feed themselves or when beginning to reintroduce oral feeding – it most closely resembles regular meals –feelings of hunger stimulate appetite and aid in the transition from tube to oral feeding

■ Type and amount of tube feedings are prescribed by the PCP and usually ranges from 240 mL to 360 mL per feeding – it may be necessary to start with a smaller amount and increase the feeding amount as the patient is able to tolerate the formula

■ A daily amount of 2,000 mL is generally sufficient to meet the patient’s nutritional requirements

■ If a syringe is used, it should be 30 mL or larger, and the formula should flow in by gravity; it should not be pushed in as a bolus or in large amounts

■ Allow about 10 minutes for an intermittent feeding to flow into the tube

■ Flush the tube with 30 mL of water after each feeding to prevent clogging

■ Continuous feedings are instilled into the tube drop by drop in much the same manner as an intravenous feeding – for this purpose, a feeding pump and a tube feeding set is used

■ Set the rate on the pump, or regulate the drop through the drip chamber to control the amount given; this device can be used with NG tubes, PEG tubes, or jejunostomy tubes

Feeding Tubes and Pumps

■ Tube feedings contain a high level of glucose to provide the necessary calories

■ Should be given slowly to prevent diarrhea and glycosuria (glucose in the urine)

■ Preferred method is to give the feedings slowly over a 24 hour period

■ When feedings are ordered for four or more times a day, the patient us usually given 150 -240 mL per feeding and advanced at a rate of 50 mL/day until the desired volume is tolerated

■ Box 27.3 Principles of tube feedings

Feeding Tubes and Pumps

■ Skill 27.3 Using a Feeding Pump

■ Skill 27.4 Administering NG, Duodenal, PEG tube feedings

Total Parenteral Nutrition

■ TPN – total parenteral nutrition - is a method of delivering complete nutrition through a catheter placed in a large central vein (such as subclavian vein)

– Large central vein is needed with high blood flow to dilute the solution rapidly

– The solution may also be infused through a port implanted in the patient’s chest wall or through a PICC – peripherally inserted central catheter

– This option is used for patients receiving long term therapy, such as those with massive burns, intestinal obstruction, inflammatory bowel disease, AIDS, and

cancer or chemotherapy

■ PPN – peripheral parenteral nutrition – shorter – term uses, a peripheral vein (usually on the arm) may be used

■ Parenteral nutrition does not involve the digestive system, and it is absorbed directly through the bloodstream

Total Parenteral Nutrition

■ Maintain aseptic technique when performing TPN administration to reduce the risk of catheter-related infection

■ Both PPN and TPN are composed of high concentrations of carbohydrates as the main source of energy

■ PPN and TPN solutions are started slowly to allow the body to adjust to the solution’s high glucose concentration and hyperosmolality (increased concentration of solutes within the fluid)

■ Usually 1000 mL to 2000 mL is administered in the first 24 hours

– After 24 hours, the infusion is increased until the desired volume is met

– Monitoring of TPN and PPN should be ongoing

– Carefully begin the infusion rate and monitor it throughout the shift - if the rate is lower or higher than the prescribed rate, adjust the infusion to correct flow rate

– NEVER attempt to catch up if the rate has slowed. The rapid infusion of glucose can be harmful to the patient

– Table 27.4

– Life Span consideration – Older Adults

Nursing Process

■ First step in assessment is to determine the reason for the tube – needed to evaluate the tube’s effectiveness

– Determine patient understanding of the procedure before beginning

– Once the tube is in place, assess the function of the tube at least every 4 hours for the first 48 hours of feeding, followed by once a shift thereafter

– Monitor for signs of complications such as nausea, vomiting, abdominal distention, abdominal pain, and respiratory distress

Nursing Process

■ Nursing measures include frequent mouth care to prevent drying and cracking of the mucous membranes

■ To keep the mouth and lips moist, swab the oral cavity with a gauze pad or cotton swab that has been moistened with normal saline and water

■ Nostrils become dry and tender, if no contraindicated, a room humidifier can be helpful for the patient who is experiencing nose and throat discomfort

■ Clean nares with a swab and warm water daily or as needed

■ Use water soluble lubricant on the nares. Other nursing actions include:

– Securing the tubing to the patient’s clothing to permit maximum activity without pulling on the nares

– Prevent kinking of the tubing

– Keeping the environment clean, quiet, and well ventilated

Nursing Process

■ Determine whether goals were met, partially met, or unmet

■ Collaborate with RN to retain, revise, or terminate nursing diagnoses, goals, or nursing interventions as appropriate

■ Evaluate patient’s ability to take food by mouth without nausea or vomiting

■ Evaluate nutritional parameters to ascertain success of tube feeding

■ Reassess abdominal peristalsis, signs of intestinal bleeding, or their absence

Key Points / Videos

■ Intermittent: https://youtu.be/RmN2fnPXc8c

■ Continuous/Pump: https://youtu.be/B5xVluzwFcM

■ NG Tube: https://youtu.be/zZ4_CcI31Bo