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CHAPTER 5 PATIENT CARE SKILLS

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Title: CHAPTER 5 PATIENT CARE SKILLS


1
CHAPTER 5PATIENT CARE SKILLS
Assisting with Enteral Nutrition
2
Assisting 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

4
Conditions 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

5
Types 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

6
Types 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.

7
Methods 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
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9
FeedingsScheduled
  • May be Scheduled or continuous feedings
  • ordered by the doctor which way to be given

10
FeedingsBolus intermittent feeding
receives a large amount of formula over a
relatively short period of time.
11
FeedingsContinuous
  • 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

12
FeedingsCyclic feeding
receives small amounts of formula constantly for
8 to 12 hours then the person is disconnected
from the feeding pump.
13
Feedings 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.

14
Children 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

15
Children 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

16
Formulas
  • 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

17
Preventing 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

18
Complications 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

19
General care measures
  • Provide oral care

20
General care measures
  • Monitor bowel movements

21
General care measures
  • Prevent complications
  • Aspiration
  • HAI
  • Dehydration
  • Dumping syndrome

22
Aspiration -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

23
ComplicationsRegurgitation
  • 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

24
Comfort 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

25
Giving 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

26
Report 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

27
Total 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.

29
Removing 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

30
Bellwork
  • 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)

31
Skill 1
  • - Giving a tube feeding
  • -see procedure in the chapter

32
Skill 2
  • -Remove a nasogastric tube
  • -see procedure in the chapter

33
SKIN 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

34
Taking a blood glucose
  • Skill practice

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

40
Nursing 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

41
Monitoring 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

42
PERFORM A SKIN PUNCTURE
43
Key Terms Genitourinary Skills
  1. Ostomy
  2. loop stoma
  3. double barrel stoma
  4. end stoma
  5. enterostomal therapy
  6. ileostomy
  7. effluent
  8. colostomy
  9. irrigation
  • stenosis
  • perforation
  • prolapse
  • diverticulitis
  • flatus
  • herniation
  • necrotic
  • peristomal

44
Ostomy 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

45
Reasons 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

46
TYPES 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

47
TYPES 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

48
TYPES 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

49
Anatomy 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.

50
Anatomy 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

51
Choosing 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

52
Choosing 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

53
Changing a pouch
  • See procedure sheet
  • 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

54
ENTEROSTOMAL 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

55
ENTEROSTOMAL 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

56
SKILL 3
  • Perform change a pouch

57
BELLWORK
  • 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)

58
Patient 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

59
SIGNS 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

60
Diet
  • 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

61
Bulk Forming Foods
  • celery
  • Chinese food
  • nuts
  • coconut
  • wild rice
  • popcorn
  • whole grains
  • coleslaw
  • seeds/kernels
  • raw veggies
  • raw fruits

62
Odor Forming Foods
  • fish
  • eggs
  • asparagus
  • onions
  • garlic
  • beans
  • peas
  • cabbage
  • turnips

63
Gas Forming Foods
  • cabbage
  • beans
  • Mexican
  • Dairy
  • Mushrooms
  • Beer
  • Carbonated drinks
  • Pickles
  • Eggs
  • Onion
  • Broccoli
  • Corn
  • Yeast
  • Spinach

64
Diarrhea
  • green beans
  • broccoli
  • spinach
  • raw fruit
  • fried foods
  • highly seasoned foods

65
Foods that Change color of stool
  • beets
  • tomatoes
  • strawberries
  • spaghetti sauce

66
Control diarrhea
  • bananas
  • applesauce
  • boiled rice
  • boiled milk
  • tapioca
  • yogurt
  • buttermilk
  • peanut butter

67
Psychological complications
  • depression
  • withdraw from activities
  • decreased self-esteem
  • change of self image

68
QUESTIONS ????????????
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