"Tube Feeding"
Closed system
Containers are sterile until spiked and hung No flexibility in formula additives (no mixing) Less nursing time-can be hung longer Less risk of contamination Increased safe hang time (more shelf stable) More expensive Hang time o 24-48 hours depending on particular formula o Y port can be used to deliver additional fluid and modular (more protein or fat) May result in less water
Nasogastric & Nasointestinal tubes
(Called feeding tube or dobbhoff). small bore (8, 10, 12 fr)
Nasogastric tubes
(Levin or Salem sump- not used for feeding- used to decompress the stomach). Size- large bore (12 fr)
PEG tube
(Percutaneous endoscopic gastric tube). Placed surgically via & tunneled under skin so 100% sure is in right place.
Bolus feeding info
-10-15 minutes administration up to 500 mL by syringe - 200 cc every (q) 4 hours or greater ... 500 ML) - Very inexpensive *No pump for administration =Only appropriate for gastric (stomach) feedings *b/c this volume/time is so high
13. Discuss the initiation recommendations for TF. How do they differ based on the osmolality of the formula? Isotonic formula....
-10-40 mL/hr then -advance 10-20 mL every 8-12 hours to goal rate
Tube feeding NRSG dx
-Altered nutrition -Altered comfort (N/V) -Fluid volume imbalance -Risk for altered metabolism -Risk for injury: aspiration
Tube Feeding Complications
-Aspiration/vomiting -Dehydration -Diarrhea
Verifying tube placement
-Auscultation -Check residuals or aspirates -check pH of residules -X-ray
Considerations for formula selection
-Calorie dense formula -Osmolarity of formula -CHO (diabetic) -Lipid (lower for heart disease) -Protein amount -More hydrolyzed, more elemental
Advantages to feeding to (ND, NJ, J-tube)
-Decreased risk of aspiration -Intestinal motility returns sooner than stomach
NG tube Complications
-Fluid and electrolyte imbalance -Mucus membrane erosion -Sore throat
Contraindications (When not to tube feed) of Tube Feeding
-GI obstruction -Shock -Client/legal guardian does not want TF -Prognosis doesn't warrant aggressive support
Fluid and electrolyte imbalance
-Gastric decompression, metabolic alkalosis -Intestinal decompression, metabolic acidosis -Dehydration
Forms of enterostomy
-Gastrostomy (G-tube, PEG, gastric tube) -Jejunostomy (j-tube, PEJ)
X-Ray method
-Gold standard method -Safest for patiens
Reasons for placement
-Gut decompression: prevent N/V post-op -To deliver nutrients -Empty stomach contents, toxins or poison
List the access (placement) sites of a tube feeding
-Orogastric -Nasoenteric (NG, ND, NJ) -Enterostomy (gastrostomy, Jejunostomy)
Gastrostomy (G-tube, PEG, gastric tube) explain
-Percutaneous endoscopic gastric tube -Placed outside in via surgery under the skin
Open system
-Product is decanted into a feeding bag -Allows modular to be added (add more protein, or fat b/c you are mixing it) -Increased food service and nursing time -Shortens hang time *Time/Temperature abuse, how long can formula sit before bacterial forms -Increased risk of contamination b/c humans con introduce bacteria during preparation -Hang time * 8 hours for decanted formula * 4 hours for modulated, formula mixtures -b/c added ingredients change environment for bacteria growth -Rinsing * Bag and tube need to be rinsed each time formula is replenished =Contaminated feedings are associated with patient infection and mortality
partially-hydrolyzed formula: describe and what situations to be used?
-Semi elemental -for patients with compromised digestion and absorption (small intestine) -mono and di saccharides -MCT, easier to metabolize -medium and short peptides =more expensive =hyperosmolar (due to particle size) =small particle size can affect how the patient responds to this feeding
Considerations for orogastric of when to use
-Used in preemies and may be used in adults with trauma to sinus area -Not very popular -No talking
Monitoring Tube feeding
-VS q4h -Blood sugar q6h -labs: everyday/everyweek -daily weights
Administering medication per NG
-assess placement and residual -NEVER ADD MED TO FORMULA -check to see if med may be crushed -crush meds and mix into H20 -aspirate med into syringe, push into tube -flush with at least 60-100 cc H20 -clamp tube X 30 minutes
Administering the feeding
-assess placement and residual. -if 100 ml or more, HOLD tube feeding for 1 hour, then reassess in 1 hour. If still more than 100, call doctor because the stomach is not emptying properly and can become distended and cause aspiration or vomiting. -check expiration date. -avoid cold feedings -clamp tubing and add formula -prime tubing and adjust drip if not on pump. Attach to tube. -flush tube with tap H20 according to policy or MD order.
cycled feeding pros
-common for non-critically ill, rahab home patient -greater freedom, can move around w/o pump or IV -benefit for transitional feedings *oral during the day; TF @ night
cycled feeding info
-continuous infusion at a higher rate for 8-16 hours -a night time feeding -100 cc/hr x 12 hrs -more flexible for patient -less time to feed means an increased formula need to be given
12. Know how to estimate water needs for a TF (non-fluid restricted) patient, based on either their weight and/or calorie recommendation.
1mL/cal 30mL/kg
Intermittent Feedings
300-500 ml several times daily over at least 30 minutes. Feedings typically given every 2-4 hours. For stable long term patients. Tolerated better if given by slow drip rather than rapid infusion.
What equipment is used?
60 ml catheter tip syringe Emesis basin or empty cup Clean gloves Cup H20 Litmus paper
Intestine pH
7-8
All clients with NG tubes/G tubes/ PEG tubes/ or feeding tubes must always be...
In fowlers position or at least 30 degrees elevation. The higher the better to prevent aspiration
Continuous NG and gastrostomy feedings
Keep gastric pH lower than usual which causes increased bacterial and fungal growth. With aspiration, this causes an increased risk of pneumonia. Reduce risk of dumping syndrome. Cause less diarrhea and more adequate intake than intermittent feeding in cases of tube feeding due to stress (EX: burns)
Enteral Feedings(tube feedings)
May be needed with: head and neck tumors, esophageal stricture coma, anorexia of chronic illness, anorexia nervosa, hyperemesis gravidarum, swallowing problems.
what feeding is only used for jejunal?
continuous because it can't tolerate a high volume
What are each nasoenteric?
nose to... -stomach NG (nasogastric) -duodenum ND (nasoduodenal) -jejunum NJ (nasojejunal)
Aspiration, safety issue w/ TB. What may help solve this problem?
o Above pyloric sphincter w/ poor LES o Verify tube is placed correctly, not close to LES o Head above bed more than 30 degrees o Check residuals-Gastric residuals-stomach contents Shows the rate the stomach is empting o If there is more than 150 cc in the stomach, hold tube feeding Residuals are given back to patient o And or Slow down rate of TF Motility drugs to increase gastric motility Post-pyloric placement instead
Advantages to Nasogastric or G-tube
o Closer to natural eating o Nothing is bypassed o Food gets digest o Stretch receptors, hunger o Greater absorption of nutrients o Still using pyloric sphincter -Controlled rate of emptying -Less risk of dumping o Normal digestion maintained o There are risks (page 4 in notes)
constipation, safety issue w/ TB. What may help solve this problem?
o Dehydration o Low fiber May not be getting enough formula to meet fiber needs o Decreased motility o GI obstruction
bacterial contamination, safety issue w/ TB. What may help solve this problem?
o Especially in open system o Aseptic technique to make and hang TF Wear gloves, wash hands, sanitize food lid o Temperature control-refrigerate, seal, labeled, dated o Cross contamination-clean workspace, new gloves oTube/Bag changes-changed and rinsed as directed 24 hours or up to 72 hours but not longer
standard tube feeding composition
o Lactose free o 1 kcal/mL o Dumping syndrome o Hard to digest
high nitrogen tube feeding compositin
o Many wounds, lots of surgery o Disease specific formulas -Critical Care +Crucial has omega 3 and arginine ( turns to nitrogen in the body) supplemented for immune system and extra antioxidants -Pulmocare •Respiratory •Very low CHO •Low CHO for respiratory disorders •Decease CO2 production
Checking for residuals or aspirates method
o Suck out stomach contents to verify we are in the stomach and see how fast they are digesting o Off white, green, tan-gastric o Yellow, green, brown-intestinal o White, yellow, clear-respiratory o Should be used secondary, too much overlap
concentrated tube feeding composition
o To give more calories w/ less volume o 1.3 - 2 kca/mL o ***Use this for renal disease or someone on fluid restriction
Lack of tube patency (opening-no clog),safety issue w/ TB. What may help solve this problem?
o Use right size of tub (French) o Irrigate tube w/ 30 - 50 mL warm water q 4 hours (continuous feeds) o Before and after every bolus o Before and after meds are administered o After stopping and before restarting o Medication should be in elixir (liquid) form if possible o Enzymes -pancreas or papain (pineapple), coke -Use these to digest a clog in tube
continuous feeding cons
restriction of moving
How to verify tube placement
x-ray
intermittent fusion info
-divided feedings administered usually 3-6 x a day -each feeding 30 - 60 minutes -200 cc every 4 hr run over 30 minutes (higher volume) *can this person's GI system and tube end point handle this volume? -similar to cycled feedings although GI intolerance risks are even more possible *aspiration due to volume *N/V due to volume *pain from over feeding *diarrhea due to dumping syndrome
Complications that might happen when a tube is misplaced
-food goes into lungs. -puncturing lungs or other body organs
Continuous feeding pros
-great for critically ill and malnourished patient -minimized risk of high residuals/aspiration *because you feed less at one time
N/V, safety issue w/ TB. What may help solve this problem?
-high infusion rate (increased volume) -delayed gastric emptying (motility drug or move tube) -intolerance to formula
Polymeric formula: describe and what situations to be used?
-intact CHO, Pro, Fat -for normal digestive capacity -meal replacement (ensure/boost) or tube feeding formula
cycled feeding cons
-may require increase protein/kcal formula -possible of GI intolerance due to increased volume
Classifications of formulas
-polymeric -partially-hydrolyzed -elemental -modular
Feeding tube insertion
-select appropriately sized tube. To determine the length of tube: measure from nose to top of ear to top of xyphiod process. -explain procedure to the patient. -lubricate tube with H20 soluble lubricant(KY jelly). -have client sit upright -have client tuck chin and neck. Insert into nares quickly and keep inserting. -encourage swallowing while tube is advanced. -after tube is in, tape tube onto nose. -if client is coughing or has difficulty breathing, remove tube immediately!!!
modular formula: describe and what situation to be used?
-single macronutrient (Just CHO/Pro/Fat) -Use this when other supplements don't fulfill patient needs -This by itself is NOT ok
Tube feeding compositions
-standard -concentrated -high nitrogen
13. Discuss the initiation recommendations for TF. How do they differ based on the osmolality of the formula? hypertonic formula.....
-starts 10-40 mL/hr then -advance more gradually as tolerated to goal -this might start out diluted
Tube Feeding Documentation
-type/size of tube -tube placement -amount of residual obtained -type of solution & volume of feedings -how client tolerates -delivery system tubing changes
Diarrhea, safety issue w/ TB. What may help solve this problem?
-volume overload -hypertonic formula -malabsorption *swap to easier digestible formula -contamination
Considerations for when to do enterostomy for feeding
-when nasoenteric placement is unavailable -TF is required for more than 3-4 weeks (irritation) -Severe head and neck trauma
Check tube placement
ALWAYS ___________ before use, and as often as necessary during use
Continuous Feedings
Administered over a 24 hour period per infusion pump (known as a kangaroo pump). Note: pump essential when feedings are administered in the small bowel.
Cyclic Feedings
Are continuous feedings administered in less than 24 hours (12-16 hours).
The nurse must...
Assess tube placement and residual at each initial assessment & Q 4 hours
Nursing actions
Assess: glucose, Na, K, Ca, Phos, Mg. BUN and creatinine CBC Serum triglycerides Serum albumin, transferrin, and pre albumin.
Why is mouth care essential?
Because of constant gastric stimulation causing increased saliva. Rinse mouth with water or mouth wash and brush teeth
What is the Auscultation method
Blow air into tube and listen
Checking for pH of residuals method
But pH can be very close to each other as well
Confirm tube placement
Check placement by aspirating gastric contents and placing on litmus paper: pH <5- in stomach or small Bowel Greater than 5.5- likely placement in lungs or large bowel
What Nursing actions do you use with an NG?
Clean nose and tube with water and Cotton applicator. Check nose for irritation/erosion. Clean made with cotton swab.
Assessment prior to oral supplement/tube feeding
Clinical signs of malnutrition or dehydration Food allergies Lactose intolerance Presence of bowel sounds Delayed gastric emptying, abdominal distention, diarrhea, or constipation.
G-tube
Gastric tube: inserted surgically into stomach
Define enteral nutrition
Delivery of nutrients to the GI tract via a tube i. orally via esophagus ii. tube feeding
What are complications of tube feedings?
Diarrhea RT to high carbs and increased GI motility. Pulmonary aspiration. Constipation (rare), due to decreased H20 if client isn't getting free water on a daily basis.
Disadvantages to feeding to ND, NJ, J-tube
Digestion is less complete -as it bypasses the pyloric sphincter (no controlled rate of emptying)
Assessment
Explain procedure Wash hands Provide privacy Check placement by aspirating gastric contents and placing on litmus paper
Problems with tube feedings
Flow may be too rapid or volume too large. Stop the feeding if the client experiences abdominal discomfort, diarrhea/nausea, tachycardia.
Enteral tubes
Nasogastric Nasogastric & Nasointestinal G-tube PEG tube
Types of tube feedings
Polymeric formula Elemental or oligomeric
Elemental or Oligomeric
Pre digested. Consists of protein hydrolystates, peptides, and free amino acids(broken down from original protein). Disease or condition specific formulas (EX: AIDS, diabetes, hepatic encephalopathy, pulmonary disease, renal failure, wound healing and critical illness)
elemental formula: describe and what situation to be used?
Predigested -free from amino acids -low in fat -high osmolality =readily absorbed w/ minimal digestive work
What to do if unable to aspirate
Reposition client onto left side
NG & feeding tube types and uses
Short term: Nasogastric (NG)- easily inserted but easily dislodged (causes aspiration). Nasoduodenal (ND) Nasojejunal (NJ) Long term: Esophagostomy Gastrostomy- must have patent esophagus. Secretions irritate skin. Jejunostomy
Tube feedings(formula)
Standard formula- 1 Kcal per ml. Calorie dense formula- 1.5 to 2.0 kilocalories/ml for those needing fluid restriction. Monitor hydration status and provide free water as needed. May be isotonic or hypertonic.
What's the only place a bolus feed can be sent to?
Stomach
Enteral feedings are used to..
Supplement or replace oral feedings. Standard formula: 1 Kcal per ml. Give bolus, intermittently, or continuously
Bolus
Syringe used to deliver the formula rapidly
Why must an abdominal x-ray be done immediately?
To see correct placement or tube in the stomach and not lungs
Tube feedings
Tube feedings are initiated at a low rate and gradually increased to prevent diarrhea. If diarrhea occurs, MD may order 1/2 or 1/4 strength formula. Nurse must dilute the feeding by adding water. 1/2 strength= 1 can formula/1 can H20 1/4 strength= 1 can formula/ 3 cans H20
Polymeric formula
Usual formula. Has protein, CHO, and fat. Fiber is found in some to help control bowel function. Most commercially prepared formula are lactose free because lactose intolerance is common among older adults and individuals with malabsorption.
Lung pH
greater than 6
Uses of oral supplement to help meet a patient's nutrient needs
i. Give these when a person is not able to eat enough food and get enough nutrients through food alone. ii. Between meals iii. Added to food (mashed potatoes, oat bran, cereals) iv. Added into liquids for medication pass v. Enhances otherwise poor intake
When to Tube Feed?
i. Inadequate oral intake: can't be able to meet their own needs orally ii. All oral diet methods exhausted (Supplements, modifications) iii. Functioning GI iv. Protein Energy Malnutrition by mouth intake for more than 5 days 1. Already malnourished by mouth 2. Have not been eating enough for more than 5 days v. Meeting less than ½ of nutrient needs my mouth for 7-10 days vi. Severe Dysphagia vii. Major Burns-> when their calorie and protein needs are very high viii. Cancer ix. Some GI complications and resections (helps the gut heal after surgery)
Benefits of TF compared to parenteral nutrition (vein)
i. Maintains gut integrity ii. Reduced infection rate iii. Safer iv. Cheaper v. Most physiologic route (most natural)
Stomach pH
less than 4
Define enterostomy
make a new opening for feeding
intermittent infusion Pro
more physicologicaly acceptable b/c we didn't eat all day long and -person can move
Bolus feeding pro
more physicologicaly acceptable b/c we didn't eat all day long and -person can move more
What is orogastric?
mouth to stomach