Enteral vs. Parental Feedings
Feeding via the GI Tract through a feeding tube, catheter or stoma.
Taken into the body in a manner other than through the digestive canal (Intravenously)
Preserves GI function
Enhances wound healing
Decreases risk of sepsis
PEG (Percutaneous Endoscopic Gastrostomy)
PEJ (Percutaneous Endoscopic Jejunostomy)
Who needs enteral feedings?
Impaired swallowing (dysphagia)
-CVA, head trauma
-Muscle disorders (MS, ALS...)
Unable/Unwilling to eat
Intractable vomiting or diarrhea,
When to start tube feedings
Enteral feeding should be started with in the first 24-48 hours of admission in critically ill patients who are receiving ventilatory support and who are hemodynamically unstable
Nasogastric Tube Uses:
Gastric Decompression (usually larger bore tube)
-Injury, disease or surgery on GI tract
Feeding (usually a smaller bore tube)
-Usually only used for short term feeding
* 4-6 weeks
* Eventually wears away mucus membranes
Nasoduodenal tubes and nasojejunal tubes
NDTs are used for delivering short-term enteral feedings (usually less than 4 weeks) because they are easy to use and are safer for the patient at risk for aspiration
NJTs are used but are the used least often
Inserting an NG Tube
Position patient sitting upright head straight
-If unable to sit up straight, may position them on their side
Measure from ear lobe, to nose, to xiphoid process - this is how much you will insert - mark the tube
Lubricate the tip of the tube & insert the tube into the nose
Ask patient to breath through mouth and swallow
Continue inserting until the mark is reached
Secure tube with tape or commercial attachment
While inserting an ng tube....
Never advance against any resistance
Stop if patient is experiencing signs of respiratory distress
Have a "stop signal" in case patient feels unsafe or in distress
Placement verification:Initial verification
X-RAY IS THE MOST ACCURATE WAY TO CHECK PLACEMENT OF AN ENTERAL FEEDING TUBE
SHOULD ALWAYS BE DONE ON INITIAL INSERTION
-Remove the guide wire after
X-ray shows correct placement
Verify placement when.....
Tube first inserted
During your initial nursing assessment
Before administering medication or feed (do so by aspirating for gastric content)
After episodes of coughing, gagging, vomiting
If patient develops s/s of respiratory distress
If you see feeding in the mouth or nose
Something just doesn't look/feel/sound right
ALWAYS HAVE HOB AT 30 degrees or more at all times!!!
AFTER THE INITIAL PLACEMENT:CHECKING VERIFICATION
CHECKING THE INITIAL MARK THAT WAS PLACED ON INSERTION
TESTING ASPIRATED CONTENT FOR PH
ASSESSING CARBON DIOXIDE FOR CAPNOMETRY
-Before administering feed or meds
-After coughing, vomiting, or gagging
-If patient develops s/s of respiratory distress
-Something just doesn't look or sound right
Checking the pH is not always accurate compared to XRAY
Capnometry tells you you placed it in the lungs or not by detecting CO2.
Is not accepted as EBP, but auscultation is the most frequent way that nurses check placement
Other ways include:
Gastric aspiration and testing the pH (antacids, trauma, blood, continuous feedings and mechanical ventilation could interfere)
-Capnography (assessing carbon dioxide levels)
NEVER ADD DYE TO TUBE FEEDINGS TO DETERMINE PLACEMENT!!!!!!!!!!
This can be toxic to the patient!
Auscultation is most practiced but its not evidence based practice
PEG vs.. PEJ
PERCUTANEOUS ENDOSCOPIC GASTROSTOMY VS PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY
Gastrostomy is a stoma created from the abdominal wall in to the stomach, through which a short feeding tube is inserted
Jejunostomy is used when it is desirable to bypass the stomach, such as with gastric disease, upper
GI obstruction, and abnormal gastric or duodenal emptying
Dual access tubes are sometimes used
PEG is in the stomach
PEJ is in jejunum....It is picked if you have problem with absorption so you bypass the stomach when pt has gastric disease or problem with gastric emptying
PEG vs PEJ
Greater risk of aspiration & GERD with PEG
PEJ also better in impaired gastric motility
Both are placed under fluoroscopy to ensure correct placement
PEG tube is greater risk for aspriration so sometimes they pick PEJ
Peg is in gastrostomy
You need an order from Md to put in Peg or Pej....they have to know many things about pt first like weight, their nutrition, etc.
When putting in feeding, you start slowly!! Like start at 10, not 60 and work up every 1 hour (^ by 10)
Aspirate for residual.
If you get high # of residual the pt is not absorbing the food (150-200)
Return the residual back to the pt cuz electrolytes might be imbalanced.
Tube Feeding initiation
Per MD order or hospital protocol
Initiated slowly to ensure patient tolerates and than increased over time
Check residuals every 4 hours until goal rate is reached
Usually dietician or MD will determine type, rate and method of tube feeding as well as the amount of additional water ("free water") needed.
Types of feedings
Bolus feedings is an intermittent feeding of a specified amount of enteral product at set intervals during a 24 hour period
Continuous feedings is similar to IV therapy in that small amounts are continuously infused over a specified time
Cyclic feedings is the same as continuous except the feedings are stopped for a specific time for bathing, treatment and other activities
Check and record the residual volume every 4 hours or per facility policy, by aspirating stomach contents into a syringe.
Residuals of >200, hold tube feedings for 1 hour and recheck.
Contact MD if residuals still elevated
Return or not to return???
-If not returned, may decrease potassium and chloride level
-If returned, may occlude the tube, although less likely if flushed with water
Residuals of >200, hold tube feedings for 1 hour and recheck
If you do return, it may occlude tube, so flush tube with water after feeding or giving med
If you don't return, it may decrease electrolyte K and Cl levels
Complications of enteral nutrition
Tube misplacement and dislodgement
Abdominal distention and nausea/vomiting
Fluid and electrolyte imbalances
Difficult to determine intolerance because may be due to other factors (meds, disease process)
S/S of Intolerance:
-Stool softeners, laxatives
-May be caused by C. Diff or bacterial contamination
FLUSH, FLUSH, FLUSH!
If administering medications/supplements that are very thick, make sure you have adequate water, administer it quickly and flush thoroughly.
Cranberry juice and soda DO NOT fix an occlusion and may even make it worse!
Try warm water first.
Get an order for Viokase which will unblock the tube.
If tube remains occluded, may need replacement.
Viokase (tube feeding line) and activase (central line) are used to unblock
Gavage vs Lavage
Aspirate secretion to check tube placement before instilling saline for flush
Gently instill saline into NGT or allow to flow by gravity
Clear BLUE PIGTAIL w/AIR to clear then reinsert anti-reflux valve
Air vent must be clear of secretions to restore proper functioning
Removes unabsorbed poisons from stomach
Activated Charcoal administration to absorb drugs in stomach (pumping the stomach)
Usually done within 60 minutes of ingestion, when possible
Induced vomiting no longer indicated
***Lavage is when your pushing something in.
Gavage is when you take something out. Gavage is garbage and you taking it out
Nutrition administered outside the GI tract
Used in patients whose GI tract is not functioning or cannot be accessed
TPN=Total Parental Nutrition
-Given through CVP or PICC
PPN=peripheral parental nutrition
-Not as nutritionally complete as TPN
-Given through peripheral IV
What is in Parental nutrition?
Carbohydrates (10%-35% glucose)
Minerals and trace elements
Electrolytes (individualized based on labs)
A commonly used solution in combination with parental nutrition
For patients receiving lipids (fat emulsions) monitor for fat overload syndrome, which symptoms include fever, increased cholesterol, clotting problems, and organ failure
Usually hung for only 12 hours, while TPN or PPN hangs for 24 hours.
Always hang below the filter, as to not clog the filter.
Order for TPN determined by MD, pharmacist, and nutritionist based on pt's labs, medical diagnosis, weight, etc.
When hanging TPN, 2 RNs must check composition and rate against written order, cuz you can kill pt with TPN
Nursing and TPN
Compare TPN label and Dr's order - JUST LIKE A MEDICATION ORDER!!!
Verify IV Pump accuracy
TPN Unavailable? Hang D10 until available
Do not attempt to "catch up" by increasing the rate if solution is running "behind"
Monitor daily wt.
Monitor electrolytes and blood sugar
Monitor for s/s electrolyte imbalances
I/O- cuz you can risk pt into fluid overload, like wet lung sounds
Assess for daily weight- fluid gain or loss (.5-1.5 kg. wk) may indicate fluid overload rather than nutritional weight gain.
Assess IV Site- is IV site infected??
INFECTION IS THE MOST COMMON COMPLICATION
Use a filter for TPN infusion, but not for lipids
Do not infuse blood or other medications into TPN line
Do not draw blood from TPN line
Do not add anything to TPN/Lipid bottle/bag
Check Daily Electrolytes
Blood glucose is checked usually every 6 hours
Labs that are also monitored are:
Prealbumin (tells you better about nutrition), albumin, triglycerides and cholesterol
Discontinuation of parental nutrition
Must be gradually discontinued and tapered down
If abruptly discontinued, may cause hypoglycemia
Must be tapered cuz can cause hypo or hyper glycemia
Complications of parental nutrition
Fluid imbalance/electrolyte imbalance
In the cardiac or renal patient:
Fluid Overload, CHF may develop