Title: CHAPTER 5 PATIENT CARE SKILLS
1CHAPTER 5PATIENT CARE SKILLS
Assisting with Enteral Nutrition
2Assisting with Enteral Nutrition
- Objectives
- Define the key terms in this chapter
- Describe the routes for enteral nutrition
- Explain the purpose of enteral nutrition
- Describe how to handle formula for enteral
nutrition - Explain the difference between scheduled and
continuous feedings - Explain how to prevent aspiration and
regurgitation - Identify the signs and symptoms of aspiration
- Describe the comfort measure that relate to
enteral nutrition - Explain the safety precautions involved in giving
tube feedings - Identify the reasons for removing a nasogastric
tube - Perform the procedures described in this chapter
giving a tube feeding, removing a nasogastric
tube.
3- Enteral nutritiongiving nutrients through the GI
tract. - Feeding tube inserted into the stomach or small
intestine. - used when food can't pass normally from the mouth
into the esophagus and into the stomach
4Conditions that are common
- cancer of the head neck, or esophagus
- trauma to face, mouth, head or neck.
- surgery to face, mouth, head, or neck.
- coma
- dementia
5Types of feeding tubesTemporary
- A. nasogastric tube (NG)
- inserted through the nose into the stomach.
- performed by a nurse or doctor
- B. nasointestinal tube (NI)
- inserted through the nose into the duodenum or
juejunum of the small intestine - doctor or RN performs procedure
6Types of tube feedingsPermanent
- A. gastrostomy
- opening into the stomach created surgically
- B. jejunostomy
- inserted into the middle part of the small
intestine - created surgically
- C. percutaneous endoscopic gastrostomy (PEG )
tube - inserted with an endoscope through the mouth and
esophagus into the stomach. - incision is made through the skin and into the
stomach, tube is inserted through the incision.
7Methods of Administering
- Syringe
- Uses a 60 ml syringe
- Flow rate is controlled by gravity
- Feeding bag
- Formula is poured into a bag hung from IV pole
- Flow rate is adjusted by the height of the bag on
the pole - Feeding pump
- Formula poured into a bag and tubing is threaded
through a machine - Rate is controlled by the pump
8(No Transcript)
9FeedingsScheduled
- May be Scheduled or continuous feedings
- ordered by the doctor which way to be given
10FeedingsBolus intermittent feeding
receives a large amount of formula over a
relatively short period of time.
11FeedingsContinuous
- require feeding pumps
- can be nasointestinal or jejunostomy tube
feedings - formula is to be kept at room temperature cold
can cause cramping - formula is added every 3 to 4 hours
- never add new formula to formula in the bag d/t
contaminated - never hang more than 4 hours to prevent the
growth of microorganisms
12FeedingsCyclic feeding
receives small amounts of formula constantly for
8 to 12 hours then the person is disconnected
from the feeding pump.
13Feedings scheduled
- usually given four times a day
- given with a syringe or feeding bag
- approximately 400 ml over 20 minutes
- amount and rate like a regular meal.
14Children and ElderlyChildren
- NG, G tube and PEG tube feedings more common
- usually scheduled not continuous
- position for feeding would be in your lap to
allow for comfort of the child - elevate the head and chest
- position on right side or Fowlers position for 1
hour (usually directed by RN) if able - amount of formula and position for feeding
directed by RN - infants get pacifiers to suck on during the
feeding to allow normal sucking reflex, comfort
and reduce crying - note cramping, vomiting, discomfort
15Children and ElderlyElderly
- increased risk of regurgitation d/t slowing of
digestion and stomach emptying - less formula and longer feeding time than other
adults - May be unable to stay on side or back for longer
than 1 hour
16Formulas
- Many different types but common factors in each
- Most contain protein, carbohydrates, fat,
vitamins, and minerals. - Commercially prepared or prepared by dietary
department in house - Can provide an environment for the growth of
microorganisms. - Must not contaminate when handling
17Preventing contamination of formulas
- Wear gloves when preparing or handling formula
- replace soiled gloves as necessary
- Do not use dented or damaged cans.
- Check the expiration date on commercial formulas.
- Check the date on formulas prepared by the
dietary department and Discard if gt24 hours - Wash cans or bottles before opening them.
- Label cans or bottles with the time and date
opened. - Refrigerate open cans or prepared formula
- Clear the tube before and after the feeding using
30-50 cc of water or other fluid per facility
policy - Counted as part of the pts intake
18Complications Aspiration
- a major complication of NG and NI tubes
- Defined as breathing of fluid or an object into
the lungs - placement can cause the tube to slip into the
respiratory tract. - must be determined by an x-ray to assure that
tube is in the stomach or SI - may move out of place with coughing, sneezing,
vomiting, suctioning, and poor positioning. - RN checks for placement before every scheduled
tube feeding, continuous every 4 to 8 hours by
aspirating GI secretions
19General care measures
20General care measures
21General care measures
- Prevent complications
- Aspiration
- HAI
- Dehydration
- Dumping syndrome
22Aspiration -signs and symptoms
- nausea
- discomfort during the feeding
- vomiting
- diarrhea
- distended abdomen
- coughing
- complaint of indigestion or heart burn
- redness, swelling, drainage, odor, or pain at
site of ostomy - elevated temp
- respiratory distress
- increased pulse
- complaints of flatulence
23ComplicationsRegurgitation
- backward flow of food from the stomach into the
mouth - can occur with NG, G, PEG tubes
- less often with NI, J tube
- common causes
- 1. delayed stomach emptying
- 2. overfeeding
- prevention
- -sitting or semi-Fowlers position for feeding
and remain for 1 hour after. - never left side lying position
24Comfort measures
- usually NPO, causes dryness of mouth, lips, sore
throat - may be allowed hard candy or gum, check care plan
- frequent oral hygiene
- lubricant for the lips
- mouth rinses
- Nose and nostrils are cleaned q 4 to 8 hours
- secure NG tube with tape to nose and gown to
relieve pressure on nose
25Giving a tube feeding You may assist the RN and
then complete on own as AP and PCT
- guidelines to follow before giving a tube feeding
- must be allowed by the state
- be in job description
- by educated and trained to perform
- know how to use the equipment at the facility
- review the procedure with the RN
- RN available to answer questions
- RN checks tube placement
- patient may have IV infusions, drainage tubes,
and breathing tube as well as GI tube. MUST KNOW
THE DIFFERENCE
26Report to the Nurse Immediately
- Abdominal pain or bloating
- Cyanosis
- Dry mucus membranes
- Nausea or vomiting
- Decreased or very concentrated urine
- Coughing or wheezing
- Diarrhea or constipation
- Difficulty breathing
- Fever
- Low reading on pulse oximeter
27Total Parenteral Nutrition How TPN Differs From
Enteral Nutrition
TPN bypasses the digestive tract and delivers the
nourishment directly into the bloodstream and is
not digested. TPN is administered through a
central line into one of the two large veins that
empty directly into the heart.
28- TPN is a solution that contains nutrients in
their smallest form. - Patients who receive TPN are very ill, injured,
or may be recovering from surgery, especially
gastrointestinal, and may not be able to tolerate
food in the digestive tract.
29Removing a nasogastric tube
- removed when the person can eat and swallow.
- must be free of nausea and vomiting
- MD orders the removal of the tube
- check job description and state regulations
- Use Standard Precautions and The Bloodborne
Pathogen Standard guidelines - report observations
- any bleeding
- pt tolerance of procedure
- pain or discomfort during or after procedure
30Bellwork
- 1. List two ways that a Patient Care Technician
can prevent contamination of enteral nutrition
formulas (1 pts) - 2. Identify the following tubes by their
placement and insertion site - (2 pts)
- nasogastric tube
- gastrostomy tube
- jejunostomy tube
- PEG tube
- 3. Define aspiration and give a common cause for
its occurrence - (1 pts)
- 4. Explain the difference between continuous
feeding and scheduled feeding - (1 pts)
31Skill 1
- - Giving a tube feeding
- -see procedure in the chapter
32Skill 2
- -Remove a nasogastric tube
- -see procedure in the chapter
33SKIN PUNCTURES
- penetration of the capillary bed in the dermis
of the skin with a lancet or other sharp device
to collect a blood specimen - especially important in pediatrics
- fingers in adults and children older than 2
- heels of infants
34Taking a blood glucose
35- Equipment
- Lancet
- microcollection tube/container
- microhematocrit tube
36- Site selection criteria-skin puncture
- warm, pink, or normal color
- free of scars, cuts, bruises, or rashes
- no cyanosis
- no edema
37- Infants
- heel recommended site for infants less than 1
year - precautions DO NOT PUNCTURE
- deeper than 2.o mm
- through previous puncture sites
- the area between the imaginary boundaries
- the posterior curvature of the heel
- in the arch causing injury to nerve, tendons, and
cartilage - areas of the foot other than the heel
38- older children and adults
- palmar surface on the distal segment of finger
- usually nondominant hand
- fleshy central portion, slightly to side and tip
- perpendicular to whorls(grooves in the
fingerprint)
39- DO NOT PUNCTURE
- Side or tip of the finger
- Parallel to grooves of the fingerprint
- causes blood to run down the finger rather than
form a round drop - The index finger
- more callused and harder to poke
- used more often and cause more pain
- Fifth or little finger
- thinnest tissue
- Fingers of infants and very young children
40Nursing Assistants Role
- Check that the dressing over the central line
insertion site is clean and dry - Notify the nurse if the dressing becomes wet,
soiled, or loose - Monitor the patients blood glucose levels
41Monitoring Glucose Levels
- The TPN solution is very concentrated and
contains a great deal of glucose - It is delivered directly into the bloodstream,
causing the body to have difficulty monitoring
and regulating the blood glucose level - Glucose levels should be monitored every 6 hours
- Patients taken off TPN should continue to have
their glucose levels checked for hypoglycemia
42PERFORM A SKIN PUNCTURE
43Key Terms Genitourinary Skills
- Ostomy
- loop stoma
- double barrel stoma
- end stoma
- enterostomal therapy
- ileostomy
- effluent
- colostomy
- irrigation
- stenosis
- perforation
- prolapse
- diverticulitis
- flatus
- herniation
- necrotic
- peristomal
44Ostomy Care
- Ostomy a surgically created opening that serves
as an exit site for fecal matter. - Colostomyan opening created anywhere along the
large intestine or colon - Ileostomyan opening into the ileum or terminal
portion of the small intestine
45Reasons for using a stoma
- Genetic defect
- Inadequate blood flow
- Removal of necrotic section
- Traumatic adnominal injury
- Disease process
- Cancer
- Diverticulitis
- Polyposis
- Crohns disease
- Ischemic bowel
- Ulcerative colitis
46TYPES OF STOMAS
- Loop stoma
- Loop of intestine is brought to the abdominal
surface - Usually temporary, closed in 2-3 months
- Bowel function returns to normal
47TYPES OF STOMAS
- Double barrel stoma
- A portion of the bowel is removed and both ends
are brought to the surface to form two stomas - Proximalfunctioning part
- Distalnon-functioning part
- May be permanent or rejoined when healed
48TYPES OF STOMAS
- End stoma
- Created when disease or pathology is present
- Affected portion and all parts below it are
removed to prevent further spread - Stoma will be proximal to affected area
- Permanent or temporary
49Anatomy review Small intestine
- -primary functions
- 1.digestion
- 2. some absorption
- -26 ft. long and one inch in diameter
- -parts
- duodenum
- jejunum
- ileum
- -effluent (output or drainage from a stoma) is
semi-liquid and caustic to the skin.
50Anatomy review Large intestine
- -two primary functions
- absorption of water
- transportation and storage of fecal matter
- -6 to 8 ft long and 2 ½ inches in diameter
- -parts
- ascending colon
- transverse colon
- descending colon
- sigmoid colon
- -effluent ranges from liquid to semi-formed to
formed depending on the location - -not as corrosive as to the skin
51Choosing a pouch system
- DETERMINING FACTORS
- 1. Type of effluent
- liquid of fairly constant would take a drainable
pouch - formed would take a security pouch with a closed
end - 2. Presence of disabilities
- - a patient with limited manual dexterity would
use a one-piece system - - a two-piece system for those who are mobile
and able to reach the ostomy site without
difficulty
52Choosing a pouch system (cont)
- 3.Personal preference
- -pt must feel comfortable and capable
- 4. Physiology
- -size and shape of the stoma
- -size and contour of the abdomen
- -peristomal skin condition -physical
activities/ manual dexterity - -opening of the skin barrier for the stoma will
continue for six to eight weeks
53Changing a pouch
- Equipment needed
- written instructions for the patient
- clean towel
- washcloth
- soap and water
- measuring guide
- flange
- pouch
- pouch clamp
- pen
- scissors
- protective skin barrier paste
- disposable bag
54ENTEROSTOMAL THERAPY
- -enterostomal therapy occurs after the stoma is
placed during surgery (therapy to help the
patient with care of the stoma and peristomal
area) - -postoperatively the enterostomal nurse (ET
nurse) is responsible for the preparation and
application of the post-op pouch and the
following responsibilities - remeasure the stoma each time the pouch is
changed - Check the pouch for leakage
- Any complaints of itching or burning should be
assumed as leakage - Empty the pouch when it is one third full of
stool or flatus (air in the intestine that causes
gas) high output post-op, then 600 to 1000cc for
2 months
55ENTEROSTOMAL THERAPY
- Monitor the stoma
- -normalred, moist, and shiny, with skin intact
- Document observations in the chart
- -amount of effluent
- -appearance of stoma
- -appearance of the peristomal area
56SKILL 3
57BELLWORK
- Explain the difference between a colostomy and an
ileostomy (1 pt) - How is the type of pouch system determined. (2
pts) - Define effluent. (1 pt)
- Determine the difference in the effluent from a
colostomy and an ileostomy (1 pt)
58Patient Education
- -teach basic anatomy and physiology, self care
techniques - how to empty the pouch
- how to measure the stoma
- how to cut the opening in the skin barrier
- how to apply the pouch and clamp
- -teach from simple to complex.
- -irrigation (cleansing the colon by flushing with
water) may be taught but will depend on the
patient and bowel function
59SIGNS OF COMPLICATIONS AND OTHER PROBLEMS
- -most require immediate attention
- skin breakdown
- blockage
- obstruction
- continuous stomal bleeding
- prolapse (a falling or dropping down the
intestine) - herniation (when the intestine protrudes into the
abdomen) - stenosis (constriction or narrowing of the
opening) - perforation (a hole made through a part)
- dehydration
60Diet
- a dietician is needed for educating the patient
post-op. - foods given post-op depend on the ostomy site
- advise to avoid foods that cause excessive odor,
flatus, constipation, or diarrhea - new foods introduced one at a time, until effects
are known
61Bulk Forming Foods
- celery
- Chinese food
- nuts
- coconut
- wild rice
- popcorn
- whole grains
- coleslaw
- seeds/kernels
- raw veggies
- raw fruits
62Odor Forming Foods
- fish
- eggs
- asparagus
- onions
- garlic
- beans
- peas
- cabbage
- turnips
63Gas Forming Foods
- cabbage
- beans
- Mexican
- Dairy
- Mushrooms
- Beer
- Carbonated drinks
- Pickles
- Eggs
- Onion
- Broccoli
- Corn
- Yeast
- Spinach
64Diarrhea
- green beans
- broccoli
- spinach
- raw fruit
- fried foods
- highly seasoned foods
65Foods that Change color of stool
- beets
- tomatoes
- strawberries
- spaghetti sauce
66Control diarrhea
- bananas
- applesauce
- boiled rice
- boiled milk
- tapioca
- yogurt
- buttermilk
- peanut butter
67Psychological complications
- depression
- withdraw from activities
- decreased self-esteem
- change of self image
68QUESTIONS ????????????