Chapter 44

Nursing process of patient with gastrostomy and jejunostomy

Assessment The focus of the preoperative assessment is to determine the patient's ability to understand and cooperate with the procedure. The nurse assesses the ability of both patient and family to adjust to a change in body image and to participate in self-care. There are multiple medical and ethical issues that the patient, the caregivers, and the primary provider should discuss together (see Chart 44-4). The purpose of the procedure and expected postoperative course should be explained. The patient needs to know that the feeding tube will bypass the mouth and esophagus so that liquid feedings can be given directly into the stomach or intestine. If the feeding tube is expected to be permanent, the patient should be made aware of this. If the procedure is being performed to relieve discomfort, prolonged vomiting, debilitation, or an inability to eat, the patient may find it more acceptable. (Hinkle 1253-1254) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file. In the postoperative period, the patient's fluid and nutritional needs are assessed to ensure proper intake and GI function. The nurse inspects the tube for proper maintenance and the incision for any drainage, skin breakdown, or signs of infection. As the nurse evaluates patients' responses to the change in body image and their understanding of the feeding methods, interventions are identified to help them cope with the tube and learn self-care measures. Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Imbalanced nutrition: less than body requirements Risk for infection related to presence of wound and tube Risk for impaired skin integrity at tube insertion site Disturbed body image related to presence of tube COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Wound infection, cellulitis, and leakage GI bleeding Premature dislodgement of the tube Planning and Goals The major goals for the patient may include achieving nutritional requirements, preventing infection, maintaining skin integrity, adjusting to changes in body image, and preventing complications. Nursing Interventions MEETING NUTRITIONAL NEEDS The first fluid nourishment is given soon after tube insertion and can consist of a sterile water or normal saline flush of at least 30 mL. Formula feeding can begin as prescribed, typically within 2 to 24 hours post tube insertion. The infusion rate or bolus amount given is gradually increased. If the tube has been placed for gastric drainage, it can be connected to either low intermittent suction or to a gravity drainage bag. This drainage should be measured and recorded because it is a significant indicator of GI function. A decrease in the amount of drainage may indicate that the tube can be clamped for periods of time, allowing greater freedom of movement. High output can result in significant fluid and electrolyte losses. PREVENTING INFECTION AND PROVIDING SKIN CARE The skin surrounding a gastrostomy or jejunostomy requires special care because it may become irritated from the enzymatic action of gastric or intestinal juices that may leak around the tube. Left untreated, the skin becomes macerated and painful. The nurse washes the area around the tube under the bumper with soap and water or 2% chlorhexidine gluconate daily and as needed to remove any encrustation. If soap and water is used, the area is rinsed well with water and patted dry. If chlorhexidine is used, the area is allowed to air dry. A protective skin barrier may be applied. Skin at the exit site is evaluated daily for signs of breakdown, irritation, excoriation, and the presence of drainage, bleeding or hypertrophic tissue growth or scattered, raised red papules that could indicate a yeast or candidal infection. Candida may appear in warm moist areas of the body; the area beneath the G tube external retention bolster is a common location for it to develop and spread. The nurse encourages the patient and family members to participate in this evaluation and in hygiene activities. A thin gauze or foam dressing is applied, if needed, under the external bumper. Dressings placed under the bumper may exert excessive tension on the tube tract (DeLegge, 2015). A tube stabilizer may also be used to anchor the G tube (Miller, McClave, Kiraly, et al., 2014). It is normal to see scant serous drainage at the site for a few days post insertion. After this drainage ceases, the site may be left open to air. The nurse rotates the tube once daily to prevent skin breakdown and buried bumper syndrome. Buried bumper syndrome can occur when there is excessive traction on the G tube from the external retention bolster to the extent that the internal fixation bolster becomes embedded in the gastric mucosa. This causes pain during tube feedings and can lead to tube obstruction and peritonitis (DeLegge, 2015). ENHANCING BODY IMAGE Eating is a major physiologic and social function, and the patient with a gastrostomy has experienced a major change in body image. The patient is also aware that gastrostomy as a therapeutic intervention is performed only in the presence of a major, chronic, or perhaps terminal illness. It is necessary to evaluate the existing family support system, because adjustment takes time and is facilitated by family acceptance. G tubes, transgastric J tubes, and G tubes with jejunal extensions can be transitioned to LPGDs and LPJDs as described previously and may be indicated to minimize the bulkiness and visibility of these tubes. MONITORING AND MANAGING POTENTIAL COMPLICATIONS During the postoperative course, the most common complications are wound infection or cellulitis at the exit site, bleeding, leakage, excessive tightness of external retention bolster, and dislodgement. Because many patients who receive tube feedings are debilitated and have compromised nutritional status, any signs of infection are promptly reported to the primary provider so that appropriate therapy can be instituted. Bleeding from the insertion site in the stomach can also occur and should be reported promptly. The nurse closely monitors the patient's vital signs and observes all operative site drainage, vomitus, and stool for evidence of bleeding. If an external retention bolster, tape, securement device, or sutures are present, they are evaluated for adequate tension and securement. Excessive tension of the external retention bolster can cause excruciating pain and will lead to skin breakdown and ulceration. The nurse should notify the primary provider if excessive pain occurs at the incision site post insertion. Dislodgement of a recently inserted tube requires immediate attention because the tract can close within 4 to 6 hours if the tube is not replaced promptly. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. The patient with a G or J tube in the home setting must be capable of maintaining patency of the tube or have a caregiver who can do so. The nurse assesses the patient's level of knowledge and interest in learning about the tube, as well as an ability to understand how to flush, provide site care, and administer feedings or facilitate decompression and drainage. Education is similar to that described earlier. To facilitate self-care, the nurse encourages the patient to participate in flushing the tube, administering medications and tube feedings during hospitalization, and establishing as normal a routine as possible. Adapters are available that can be secured to the end of the tube to create a "Y" site for ease of flushing, suction, or medication delivery. The flushing equipment is cleaned with warm, soapy water and rinsed after each use. The tube can be marked at skin level to provide the patient with a baseline for later comparison. The patient or caregiver should be advised to monitor the tube's length and to notify the primary provider or home care nurse if the segment of the tube outside the body becomes shorter or longer. Continuing and Transitional Care. Referral to home, community-based, or transitional care is important to ensure initial supervision and support for the patient and caregiver. The nurse assesses the patient's status and progress and evaluates the care of the tube and healing status of the tube insertion site. Further instruction and supervision in the home setting may be required to help the patient and caregiver adapt to a physical environment and equipment that are different from the hospital setting (see Chart 44-5). The nurse also reviews with the patient and caregiver what complications to report and assists the patient and family in establishing as normal a routine as possible. Evaluation Expected patient outcomes may include: Achieves nutrition goals Attains weight goal Tolerates tube feeding prescription without nausea, emesis, cramping, abdominal pain, or feelings of early satiety Has acceptable bowel movements without constipation or large-volume liquid stools Has normal plasma protein, glucose, vitamin, and mineral levels Has normal electrolyte values Is free of infection at enteral access site Is afebrile Has no induration, redness, pain, or purulent drainage Has no scattered papules indicative of a yeast infection Has dry, intact skin surrounding enteral access site No evidence of excessive drainage or bleeding No skin breakdown or hypertrophic tissue growth Adjusts to change in body image Is able to discuss expected changes Verbalizes concerns Demonstrates skill in tube care Handles equipment competently Demonstrates how to maintain tube patency Keeps an accurate record of I&O Demonstrates how to gently wash tube site daily and keep clean and dry Avoids other complications Exhibits adequate wound healing Tube remains intact and is routinely replaced for the duration of therapy (Hinkle 1254-1256) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Nursing process of patient receiving parenteral nutrition

Assessment The nurse assists in identifying patients unable to tolerate oral or enteral feedings who may be candidates for PN. Indicators include significant weight loss (10% or more of usual weight), a decrease in oral food intake for more than 1 week, muscle wasting, decreased tissue healing, abnormal urea nitrogen excretion, and persistent vomiting and diarrhea (McClave et al., 2016). The nurse carefully monitors the patient's hydration status, electrolyte levels, and calorie intake. Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: Imbalanced nutrition: less than body requirements related to inadequate oral intake of nutrients Risk for infection related to contamination of the central catheter site or infusion line Risk for imbalanced fluid volume related to altered infusion rate Risk for activity intolerance related to restrictions because of the presence of IV access device COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS The most common complications are pneumothorax, air embolism, a clotted or displaced catheter, sepsis, hyperglycemia, fluid overload, and rebound hypoglycemia. These problems and the associated collaborative interventions are described in Table 44-5. Planning and Goals The major goals for the patient receiving PN may include optimal level of nutrition, absence of infection, adequate fluid volume, optimal level of activity (within individual limitations), knowledge of and skill in self-care, and absence of complications. Nursing Interventions MAINTAINING OPTIMAL NUTRITION A continuous, uniform infusion of PN solution over a 24-hour period is desired. However, in some cases (e.g., home care patients), cyclic PN may be appropriate. Cyclic PN is infused during a set period of time. The time periods for infusion are sufficient to meet the patient's nutritional and pharmacologic needs. Ideally, cyclic PN is infused over a 10- to 15-hour period that continues through the night. The cyclic PN is titrated up during the beginning of the infusion cycle and down at the conclusion of the infusion to prevent hyperglycemia and hypoglycemia, respectively. The patient is initially weighed daily (this may be decreased to 2 or 3 times per week once stable) at the same time of the day under the same conditions for accurate comparison. Under the PN regimen, satisfactory weight maintenance or gain can usually be achieved. It is important to keep accurate I&O records and calculations of fluid balance. A calorie count is kept of any oral nutrients. Trace elements (copper, zinc, chromium, manganese, and selenium) are included in PN solutions and are individualized for each patient. PREVENTING INFECTION The high dextrose and fat content of PN solutions makes them an ideal culture medium for bacterial and fungal growth, and CVADs provide a port of entry. Gram-positive cocci, Gram-negative bacilli, and Candida species are frequently isolated as causes of CLABSI. Common organisms include Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, Acinetobacter species, and Klebsiella pneumoniae. Quality and Safety Nursing Alert Meticulous aseptic technique is essential to prevent infection any time the IV line setup is manipulated. The skin and the catheter hub are the major sources for CLABSIs. The catheter site is covered with a chlorhexidine disc or gel and semipermeable transparent film dressing. The semipermeable transparent dressing allows frequent examination of the catheter site, adheres well to the skin, and is more comfortable for the patient. The transparent semipermeable membrane CVAD dressing is changed every 7 days unless the dressing is damp, bloody, loose, or soiled. Alternatively, an occlusive gauze dressing may be used and is changed every 48 hours or as needed (Gorski et al., 2016). During dressing changes, the nurse and patient wear masks to reduce the possibility of airborne contamination. Sterile technique is used (e.g., the nurse wears sterile gloves). The area is checked for leakage; bloody or purulent drainage; a kinked catheter; and skin reactions such as inflammation, redness, swelling, or tenderness. If chlorhexidine is used for skin asepsis, it is important to allow it to completely dry before applying the new dressing to avoid skin irritation. (Hinkle 1259-1260) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file. The catheter is another major source of colonization and infection. The use of chlorhexidine/silver sulfadiazine- or minocycline/rifampin-impregnated catheters is recommended for a patient whose catheter is expected to remain in place for longer than 5 days if there is concern over a possibility of the patient acquiring a CLABSI (National Healthcare Safety Network, 2015). MAINTAINING FLUID BALANCE The ubiquitous use of infusion pumps ensures that an accurate rate of PN administration can be achieved. A designated rate is set in milliliters per hour (i.e., mL/hr), and the rate is routinely verified per institution policy, generally every 4 hours. The infusion rate should not be increased or decreased to compensate for fluids that have infused too quickly or too slowly. If the solution runs out, 10% dextrose and water is infused at the same rate to prevent hypoglycemia until the next PN solution is available for administration. If the rate is too rapid, hyperosmolar diuresis can occur. Excess glucose is excreted by the renal tubules, pulling large volumes of water into the tubules via osmosis, resulting in higher-than-normal urine output and intravascular fluid volume deficit. If the flow rate is too slow, the patient does not receive the maximal benefit of calories and nitrogen. I&O is recorded every 8 hours so that fluid imbalance can be readily detected. ENCOURAGING ACTIVITY Activities and ambulation are encouraged when the patient is physically able. With a central catheter, the patient is free to move the extremities, and normal activity should be encouraged to maintain good muscle tone. If applicable, the education and exercise program initiated by occupational and physical therapists is reinforced. Chart 44-6 ASSESSMENT Assessing for Home Nutrition Support Be alert to the following assessment findings: Water: Water is necessary for hand hygiene and cleaning of work areas. Electricity: A reliable power source is needed to provide proper lighting and charging of pumps. Refrigeration: Refrigeration must be adequate for accommodation of several bags of parenteral nutrition solution. Telephone: A telephone is necessary for contacting home health personnel, arranging for prompt delivery of supplies, and for emergency purposes. Environment: Should be free of rodents and insects Should have storage that is not accessible to pets and small children Should be assessed for stairs, carpets, and inaccessible areas, which can limit mobility with infusion pumps if the patient has a disability Adapted from Durfee, S. M., Adams, S. C., Arthur, E., et al.; Home and Alternate Site Care Task Force and the American Society for Parenteral and Enteral Nutrition (ASPEN). (2014). ASPEN standards for nutrition support: Home and alternate site care. Nutrition in Clinical Practice, 29(4), 542-555. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. Successful home PN requires educating the patient and family in specialized skills using an intensive training program and follow-up supervision in the home. This is best accomplished through a team effort. Initiation of a home program facilitates the patient's discharge from the hospital. Ideal candidates for home PN are patients who have a reasonable life expectancy after return home, have a limited number of illnesses other than the one that has resulted in the need for PN, and are highly motivated and fairly self-sufficient. Ethical dilemmas occur when the patient and family, as well as the caregiver, do not thoroughly understand what is involved in home PN. In addition, the ability to learn, availability of family interest and support, adequate finances, and physical plan of the home are factors that must be assessed when the decision about home PN is made (see Chart 44-6). Many home health care agencies have developed education brochures and videos for home PN treatment. Topics include catheter and dressing care, the use of an infusion pump, administration of fat emulsions, and catheter maintenance. Education begins in the hospital and continues in the home or ambulatory infusion center. Continuing and Transitional Care. The home, community-based, or transitional care nurse should be aware that the typical patient needs several instruction sessions for assessment of learning and reinforcement. More information about home patient education is presented in Chart 44-7. Special considerations for older adult patients who go home with nutrition support are presented in Chart 44-8. Evaluation Expected patient outcomes may include the following: Attains or maintains nutritional balance Is free of catheter-related infection Is afebrile Has no purulent drainage from the catheter insertion site Is hydrated, as evidenced by good skin turgor Achieves an optimal level of activity, within limitations Demonstrates skill in managing PN regimen Prevents complications Maintains proper catheter and equipment function Maintains metabolic balance within normal limits (Hinkle 1260-1261) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Maintaining bowel elimination pattern

Patients receiving gastric or enteric tube feedings can experience diarrhea or constipation. Possible causes of diarrhea include: Malnutrition: A decrease in the intestinal absorptive area can cause diarrhea. (Hinkle 1250) Medication therapy: Elixir-based medications—often contain sorbitol, which can act as a cathartic Magnesium—acts as a cathartic Antibiotics—thought to alter normal intestinal flora, allowing pathogenic bacteria to flourish Clostridium difficile (C. difficile) colitis: Can result after antibiotic use alters normal intestinal flora and promotes the abnormal growth of this potentially dangerous microbe. C. difficile colitis occurs most commonly in hospitalized older adult patients treated with antibiotics and causes significant, potentially lethal diarrhea (Gupta & Khanna, 2014). Zinc deficiency: Zinc is lost with diarrhea, and zinc deficiency can then cause continued diarrhea. Concomitant lactose intolerance Concomitant hyperthyroidism Dumping syndrome: Formula is infused into the small intestine quickly or formula bypasses the stomach too readily into the small intestine and causes expansion of the intestinal wall. This leads to bloating, cramping, diarrhea, dizziness, diaphoresis, and weakness. Measures for managing the GI symptoms associated with dumping syndrome are presented in Chart 44-3. Contamination of the formula and feeding equipment with diarrhea-causing pathogens Possible causes of constipation include: Inadequate water intake: Tube feedings typically do not meet total fluid needs and additional water needs to be given. Administration of fiber-free tube feeding formulas Concomitant use of opioids p. 1251 p. 1252 Chart 44-3 Preventing Dumping Syndrome The following strategies may help prevent some of the uncomfortable signs and symptoms of dumping syndrome related to tube feeding: Slow the formula instillation rate to provide time for carbohydrates and electrolytes to be diluted. Administer feedings at room temperature, because temperature extremes stimulate peristalsis. Administer feeding by continuous drip (if tolerated) rather than by bolus, to prevent sudden distention of the intestine. Advise the patient to remain in semi-Fowler position for 1 hour after the feeding; this position prolongs intestinal transit time by decreasing the effect of gravity. Instill the minimal amount of water needed to flush the tubing before and after a feeding, because fluid given with a feeding increases intestinal transit time. Maintaining Adequate Hydration The nurse carefully monitors hydration because in many cases the patient cannot communicate the need for water. Water flushes are given every 4 hours and after feedings to prevent hypertonic dehydration. The feeding may be initially given as a continuous drip in order to help the patient develop tolerance, especially for hyperosmolar solutions. Key nursing interventions include observing for signs of dehydration (e.g., dry mucous membranes, thirst, decreased urine output); administering water routinely; and monitoring I&O, residual volume, and fluid balance. Promoting Coping Ability The psychosocial goal of nursing care is to support and encourage the patient to accept physical changes and to convey hope that daily progressive improvement is possible. If the patient is having difficulty adjusting to the treatment, the nurse intervenes by encouraging self-care within the parameters of the patient's activity level. In addition, the nurse reinforces an optimistic approach by identifying indicators of progress (daily weight trends, electrolyte balance, absence of nausea and diarrhea, improvement in plasma proteins). Promoting Home, Community-Based, and Transitional Care Educating Patients about Self-Care Patients who require long-term tube feedings may have had recent surgery, dysphagia due to a neuromuscular disease, radiation or other types of trauma to the throat, an obstruction of the upper GI tract, or decreased level of consciousness. For a patient to be considered for tube feeding at home, the patient should: Be medically stable and successfully tolerating at least 60% to 70% of the feeding regimen Be capable of self-care or have a caregiver willing to assume the responsibility Have access to supplies and interest in learning how to administer tube feedings at home Preparation of the patient for home administration of enteral feedings begins while the patient is still hospitalized. The nurse should educate the patient and caregiver while administering the feedings so that they can observe the mechanics and participate in the procedure, ask questions, and express any concerns. Before discharge, the nurse provides information about the equipment needed, formula purchase and storage, and administration of the feedings and water flushes (frequency, quantity, rate of instillation). Family members who will be active in the patient's home care are encouraged to participate in education sessions. Available printed information about the equipment, the formula, and the procedure is reviewed. Arrangements are made to obtain the equipment and formula and have it ready for use before the patient's discharge. Continuing and Transitional Care Referral to home, community-based, or transitional care is important so that a nurse can supervise and provide support during the first tube feedings at home. Additional visits will depend on the skill and comfort of the patient or caregiver in administering the feedings. During all visits, the nurse monitors the patient's physical status (weight, hydration status, vital signs, activity level) and the ability of the patient and family to administer the tube feedings correctly and assess the enteral access device and site. Enteral access devices require periodic replacement, and the nurse should be sure that the patient and caregiver have the necessary information to set up these tube replacement appointments. In addition, the nurse assesses for any complications. The patient or caregiver is encouraged to record times and amounts of feedings and water flushes, bowel patterns, and any symptoms that occur. The nurse can review the record with the patient and caregiver during home visits. (Hinkle 1251-1252) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Maintaining feeding equipment and nutritional balance

The temperature and volume of the feeding, the flow rate, and the patient's total fluid intake are important factors to consider when tube feedings are given. The schedule of tube feedings, including the correct quantity and frequency, is maintained. The nurse must carefully monitor the drip rate and avoid administering fluids too rapidly. For patients receiving tube feedings, measuring gastric residual volumes (GRVs) by removing gastric contents with a large syringe at routine intervals has been a commonly prescribed practice; however, the usefulness of measuring GRVs has not been validated by research (Reignier, Mercier, Le Gouge, et al., 2013; Williams, Leslie, Mills, et al., 2013). Previously, GRV in excess of 250 to 500 mL had been thought to indicate feeding intolerance. Other measures of feeding tolerance that the nurse may employ include physical assessment findings such as abdominal distention, patient reports of discomfort, vomiting, changes in passing flatus, and presence of diarrhea (McClave et al., 2016). The most recent guidelines for assessment and provision of nutrition in the patient who is critically ill, authored by the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN), do not advocate using GRVs to monitor tolerance of enteral feedings (McClave et al., 2016). Recent research shows that GRVs between 250 and 500 mL did not increase the incidence of vomiting, aspiration, or pneumonia (McClave et al., 2016). Growing evidence supports moving away from routine assessment of GRVs (Seres, 2016). (Hinkle 1249-1250) Maintaining tube function is an ongoing responsibility of the nurse, patient, primary provider, and caregiver. To ensure patency and to decrease the chance of bacterial growth, sludge build-up, or occlusion of the tube, at least 30 mL of water is given in each of the following instances (Blumenstein et al., 2014). Before and after intermittent tube feeding and medication administration (with at least 5 mL of water in between each individual medication) After checking for gastric residuals and gastric pH Every 4 hours with continuous feedings When the tube feeding is discontinued or interrupted for any reason When the tube is not being used, where a minimum of once daily flushing is recommended Water used to irrigate these tubes must be recorded as fluid intake. Sterile water or sterile saline should be used for patients who are immunocompromised or to flush postpyloric nasoduodenal and jejunostomy tubes (Blumenstein et al., 2014). Potential complications of enteral therapy are noted in Table 44-3. (Hinkle 1250) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Administration methods

The tube feeding method chosen depends on the location of the tube in the GI tract, patient tolerance, convenience, and cost. Large-bore (larger than 12 Fr) gastric tubes can be uncomfortable and their usefulness for tube feedings is limited; however, they may be used for administration of feedings for several days (Brantley & Mills, 2012). Small-bore tubes manufactured for tube feedings are better tolerated; however, they require diligent monitoring and frequent flushing to remain patent. Bolus and intermittent drip tube feeding methods are practical and inexpensive options for the patient receiving tube feedings who resides at home or in a long-term care facility; however, they may be poorly tolerated in patients who are acutely ill. Bolus feedings typically are divided into 3 to 4 feedings daily and can be given into the stomach through a large syringe with a plunger or by gravity (see Fig. 44-3). Bolus feedings can be delivered as quickly as the patient can tolerate them but are initiated slowly, increasing the rate as tolerated. With gravity feedings, raising or lowering the syringe above the abdominal wall regulates the rate of flow. The amount and flow rate is often determined by the patient's reaction. If the patient feels full, it may be desirable to slow the delivery time or give smaller volumes more frequently. The intermittent gravity drip feeding method requires administering feedings over 30 minutes or longer at designated intervals by a reservoir enteral bag and tubing, with the flow rate regulated by a roller clamp or automated pump. Figure 44-3 • Bolus gastrostomy feeding by gravity. Syringe is raised perpendicular to the abdomen so that feeding can enter by gravity. Figure 44-4 • Nasoenteric tube feeding by continuous controlled pump. The head of the bed should be elevated to prevent aspiration. Continuous feeding is the delivery of feedings incrementally by a slow infusion over long periods. Slow drip feedings may reduce aspiration rates, distention, nausea, vomiting, and diarrhea in patients with poor gastric emptying or who are receiving hypertonic feeding solutions, as well as patients with severe reflux or altered mental status (Blumenstein, Shastri, & Stein, 2014). This method may also be used to administer tube feedings into the small intestine. Enteral feeding pumps control the delivery rate of the formula (see Fig. 44-4). They allow for a constant flow rate and can infuse a viscous formula through a small-diameter feeding tube. However, they do not allow the patient as much flexibility as intermittent feedings. Portable lightweight enteral pumps are available for home use. In addition, feeding pumps have built-in alarms that signal when the bag is empty, the battery is low, or the tube is occluded. The patient and caregiver need to be aware of these alarms and know how to "troubleshoot" the pump. An alternative to the continuous infusion method is cyclic feeding, in which the infused feeding is given by an enteral feeding pump over 8 to 18 hours. Feedings may be infused at night to avoid interrupting the patient's lifestyle. Cyclic infusions may be appropriate for patients who are being weaned from tube feedings to an oral diet, for patients who cannot eat enough and need supplements, and for patients at home who need daytime hours free from the pump. Key assessment findings for patients receiving tube feedings are noted in Chart 44-2. (Hinkle 1249) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Caring for the tubes

If it is difficult to instill or withdraw contents from a feeding tube, several declogging steps can be taken, including warm water irrigation, milking the tube, infusing digestive enzymes, and employing mechanical declogging devices. For the procedural guidelines for declogging a feeding tube, go to thepoint.lww.com/Brunner14e. A premanufactured declogging kit, such as the Clog Zapper, contains a syringe filled with enzymatic powder that is activated by pulling in water. An elongated hollow catheter is attached to this syringe so that the declogging solution gains close proximity to the clog. Inserting and twisting endoscopy or cytology brushes and commercial mechanical declogger devices into the feeding tube can only be used with larger-bore tubes and should be performed only by experienced providers. Of note, even though cola and cranberry juice are sometimes used to declog tubes, these fluids are not advocated because their acidic nature has been shown to worsen formula clogs by causing precipitation of proteins (Metheny, Eisenberg, & McSweeney, 1988; Nicalou & Davis, 1990; Wilson & Hayes-Johnson, 1987). Quality and Safety Nursing Alert Feeding tubes are more successfully declogged when intervention is initiated immediately after the obstruction is noted. Monitoring the Patient and Maintaining Tube Function Tubes used for enteral nutrition are attached to enteral delivery tubing or a syringe that contains the feeding formula. They can be connected continuously for pump feedings or intermittently (bolus feeding) so that the end of the tube may be capped between feedings. Malposition or dislodgement of the tube may be caused by tension on the tube with patient movement, coughing, suctioning, or airway intubation. The nurse must keep an accurate record of all fluid intake, feedings, and irrigation volumes. To maintain patency, the tube is irrigated with water after every feeding and medication delivery and every 4 to 6 hours during continuous feedings, or if the tube is set to gravity drainage or suction. Sterile saline or water, or tap water can be used as irrigants, depending on the patient's electrolyte levels and ability to fight infection. The nurse records the amount, color, and type of drainage. When double- or triple-lumen tubes are used, each lumen is labeled according to its intended use for drainage, medication delivery, or feeding. Providing Oral and Nasal Hygiene Regular, conscientious oral and nasal hygiene is a vital part of patient care because the tube may cause discomfort and pressure, and may be in place for an extended length of time. The nose is inspected daily for skin irritation, and the nasal tape is changed every 3 days and as needed. If the nasal and pharyngeal mucosae are excessively dry, steam or cool vapor inhalations may be beneficial. Throat lozenges, an ice collar, chewing gum, or sucking on hard candies (if permitted) and limiting talking also assist in relieving patient discomfort. Monitoring and Managing Potential Complications Patients with gastric or enteric intubation are susceptible to a variety of problems, including inadvertent misconnections and administrations, fluid volume deficit, pulmonary complications, and tube-related irritations. These potential complications require careful ongoing assessment. The Institute for Safe Medication Practices (ISMP) has reported significant errors with inadvertent administration of liquid enteral medications into intravenous (IV) lines. To create a safer environment, a new industry-wide standard for enteral feeding connectors (which are incompatible with Luer lock or small-bore syringes) known as the ENFit is in the process of being fully implemented for use in all feeding tubes, feeding syringes, and feeding administration sets (ISMP, 2015; Joint Commission, 2014) (see Fig. 44-2). The nurse should be vigilant for symptoms of fluid volume deficit in patients receiving enteral nutrition. These can include dry skin and mucous membranes, decreased urinary output, lethargy, lightheadedness, hypotension, and increased heart rate. Assessment involves maintaining an accurate record of intake and output (I&O). This includes measuring fluid intake from tube feeding and flushes, oral liquids, and intravenous (IV) fluids. Output of urine, emesis, gastric drainage, diarrhea, ostomies, fistulas, and drainage tubes should also be measured. The nurse assesses 24-hour fluid balance and reports negative fluid balance (output greater than intake, increased gastric tube output, interruption of IV therapy, or any other disturbance in fluid I&O). See Chapter 13 for further discussion of fluid volume deficit. Pulmonary complications from gastric intubation can occur because coughing and clearing of the pharynx are impaired. Tubes may become malpositioned, retracting the distal end above the esophagogastric sphincter. Aspiration pneumonia occurs when regurgitated stomach contents or enteral feedings from an improperly positioned feeding tube are instilled into the pharynx or the trachea or when oral secretions are aspirated. Feeding patients through tubes placed beyond the pylorus or using prokinetic agents (e.g., erythromycin, metoclopramide) can decrease the frequency of feeding regurgitation and aspiration. In addition, feedings and medications should always be given with the patient in the semi-Fowler position, and the patient's head should be elevated at least 30 to 45 degrees to reduce the risk of reflux and pulmonary aspiration. This position is maintained at least 1 hour after completion of an intermittent tube feeding and is maintained whenever possible for patients receiving continuous tube feedings. A reverse Trendelenburg position can be considered when it is not possible or advisable to elevate the head of the patient's bed. Figure 44-2 • A. ENFit connections on tubing. B. ENFit connection on syringe. C. ENFit connections on feeding bag. Reprinted with permission from Medline Industries. Patients at risk for aspiration pneumonia include those older than 70 years of age, unable to protect their airways, with altered mental status or other neurologic deficits, receiving mechanical ventilation, with gastric or enteral tubes, and in the supine position (McClave, Taylor, Martindale, et al., 2016). Although it has been thought that enteral feedings should be withheld when patients receiving mechanical ventilation are repositioned, research findings question the advisability of this practice (DiLebero, Lavieri, O'Donoghue, et al., 2015) (see Chart 44-1). Signs and symptoms of pulmonary complications include coughing during the administration of foods or medications, difficulty clearing the airway, tachypnea, and fever. Assessment includes regular auscultation of lung sounds and monitoring of vital signs and laboratory values. The nurse also carefully confirms the proper placement of the tube with a variety of methods before instilling any fluids or medications. If tube position is ever in question, radiographic confirmation is essential (Metheny, 2016). (Hinkle 1246-1247) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Gastric or enteric tubes for feeding

Some enteral tubes are manufactured to administer tube feedings, fluids, and medications. These tubes are made of various materials, including rubber, polyurethane, and silicone. They vary in length, diameter (Fr size), purpose, and placement in the GI tract. They are smaller bore (generally 5 to 12 Fr) than the tubes made for gastric decompression and drainage, which lessens patient discomfort and nasal irritation. An orally or nasally placed feeding tube is for short-term use and should stay in place for no more than 4 weeks before being replaced with a new tube (Brantley & Mills, 2012) (see later discussion on stomal tubes). Any feeding solution given through a tube is regulated by a feeding infusion pump, poured through a syringe, or delivered by gravity drip. Gastric or enteric (of or relating to the intestines) feeding tubes are used for patients who have the ability to receive and process nutrition, fluids, and medications adequately by the gastric route. For patients who have gastroparesis (reduced stomach motility), severe gastroesophageal reflux disease, impaired glottic closure, or undergone partial or total gastrectomy, or otherwise are at risk for aspiration (inhalation of substances into the airways), a nasoenteric tube (i.e., inserted through the nose into the stomach and beyond the pylorus into the small intestine) or oroenteric tube (i.e., inserted from the mouth to the small intestine) for feeding can be used. Enteric tubes placed in the duodenum via the nares are called nasoduodenal tubes, whereas those placed in the jejunum (the portion of the small intestine distal to the duodenum) via the nares are called nasojejunal tubes. They can be inserted at the bedside, during surgery, fluoroscopically, or endoscopically. Due to the risk of complications associated with blind insertion of small bowel feeding tubes, some organizations only allow physicians or advanced practice clinicians (e.g., nurse practitioners, physician assistants) to insert these tubes (Hodin & Bordeianou, 2015). The nurse should demonstrate competency in and knowledge of small bowel feeding tube placement according to the Nurse Practice Act applicable in their state and should follow the rules and regulations, organizational policies and procedures, and practice guidelines of that state's board of nursing. Nasally inserted feeding tubes are soft and pliable; therefore, they may kink when a stylet (a stiff wire placed in a catheter or other tube that allows the tube to maintain its shape) is not used during insertion, particularly if the patient is unable to swallow. However, caution is required when inserting feeding tubes with a stylet because there is a risk of tissue puncture or placement error. Some enteric feeding tubes are weighted at the tip to facilitate movement into the duodenum; others are nonweighted. Enteric tubes are never inserted in patients with basilar skull fractures, in those who have had maxillofacial surgery (including transsphenoidal approaches) or facial trauma, or in those with uncontrolled coagulation abnormalities (Hodin & Bordeianou, 2015). Nurses should also use caution when inserting these tubes in patients with esophageal varices due to the increased risk of bleeding. During nasal insertion, the tip of the tube is initially directed toward the back of the nose, through the esophagus and into the stomach, and is further advanced through the pylorus into the small intestine if warranted. Fluoroscopic techniques may be used to visually direct feeding tubes into the stomach, duodenum, or jejunum. Several bedside techniques may be used to facilitate tube tip placements into the small intestine. These techniques include using air insufflation or manipulating the tube itself as it is being inserted (e.g., using a "corkscrew" technique). Research findings are inconclusive regarding the efficacy of prokinetic agents such as metoclopramide (Reglan) or erythromycin to facilitate movement of the feeding tube by peristalsis (involuntary wavelike movement) into the duodenum (Heuschkel & Duggan, 2015). Some postpyloric feeding tubes, such as the Cortrak Enteral Access System or the Syncro BlueTube, have a magnetized tip and an external magnet device that is used with a bedside monitor to provide a visual guide during insertion. Use of these specific tubes precludes the need for postinsertion x-ray placement verification (Smithard, Barrett, Hargroves, et al., 2015). Although still widely used in practice, small bowel feeding tubes with tungsten-weighted tips do not always facilitate migration of the tube from the stomach into the intestine (Heuschkel & Duggan, 2015). (Hinkle 1245-1246) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Gastrostomy and jejunostomy

A gastrostomy is a procedure in which an opening is created into the stomach either for the purpose of administering nutrition, fluids, and medications via a feeding tube, or for gastric decompression in patients with gastroparesis, gastroesophageal reflux disease, or intestinal obstruction. A gastrostomy is preferred over a nasally inserted tube to deliver enteral nutrition support longer than 4 weeks (Blumenstein et al., 2014). Gastrostomy is also preferred over nasogastric or orogastric feedings in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely. Balloon and non-balloon gastrostomy tubes (G tubes) may be placed surgically, endoscopically, or fluoroscopically. Each technique requires an abdominal incision, and either a permanent gastric stoma (an artificially created opening) is created surgically that can be accessed with a feeding tube (Janeway gastrostomy), or a gastric stoma is established that remains open as long as it remains intubated (i.e., a tube remains in place). Insertion of a percutaneous endoscopic gastrostomy (PEG) requires the services of a provider skilled in endoscopy and utilizes moderate sedation. A lighted endoscope is inserted via the patient's mouth toward the stomach and then the stomach is inflated with air. The PEG tube is guided down the esophagus, into the stomach, and out through the abdominal incision. An internal fixation bolster is pulled snug against the stomach wall. An external retention bolster (crossbar, circular, or star shaped) is threaded down the tube and positioned snug to the skin. The tension between the external and internal fixation bolsters keeps the tube in place (see Fig. 44-5A). G tubes can also be placed fluoroscopically by a skilled provider when an endoscope cannot be passed through a strictured or obstructed esophagus (DeLegge, 2015). Figure 44-5 • A. A detail of the abdomen and the percutaneous endoscopic gastrostomy tube showing catheter fixation. B. A detail of the abdomen and the nonobturated low-profile gastrostomy device showing balloon fixation. The initial G tube can be removed and replaced once the tract is well established, typically 6 weeks to 3 months after initial insertion. Routine replacement is indicated every 3 to 6 months for a balloon G tube and every 6 to 12 months for a non-balloon G tube. Replacement is also indicated for a tube that has clogged or fractured or has a ruptured balloon. The external G tube retention bolster should be fitted snugly to the stoma to prevent leakage of gastric secretions and is maintained in place through gentle traction between the internal and anchoring devices. The G tube site is cleaned daily and as needed with soap and water, or 2% chlorhexidine gluconate according to institution policy, and dried thoroughly. The site is assessed for tube deterioration, drainage, and signs and symptoms of possible infection, including redness, swelling and foul-smelling drainage. Abnormal findings are communicated to the primary provider. If there is excessive drainage, a gauze pad may be secured over the external anchor, taking caution to avoid excessive tension on the tube (Arora & Lukens, 2015; DeLegge, 2015). An alternative to G tubes that are bulky (e.g., they are usually coiled under an elastic binder or secured to the abdomen with tape or some type of attachment device) are low-profile gastrostomy devices (LPGDs) (see Fig. 44-5B). Specific types of LPGDs include the MIC-KEY or the Bard Button. LPGDs may be inserted 6 weeks to 3 months after initial G tube placement or placed as the initial G tube. These devices are flush with the skin, eliminate the possibility of inward tube migration, have antireflux valves to prevent gastric leakage, and do not require tape or other securement devices. Patients requiring enteral nutrition support are able to conceal the feeding tube access site under their clothing. LPGDs require special connection tubing so they can be attached to the feeding container. Patients must be instructed to bring this connection tubing with them when traveling, going to the emergency department or hospital, or undergoing diagnostic procedures that require access into the GI tract. A jejunostomy is a surgically placed opening into the jejunum for the purpose of administering nutrition, fluids, and medications. A jejunostomy tube (J tube) is indicated when the gastric route is not accessible, or to decrease aspiration risk when the stomach is not functioning adequately to process and empty food and fluids (Gangadharan, 2015). The small intestine can also be accessed by placing a jejunal extension tube through an existing G tube and manipulating it through the pylorus into the small intestine endoscopically, fluoroscopically, or during a surgical procedure. A transgastric J tube can be placed that contains both a gastric and jejunal port so that both the stomach and small intestine can be accessed. There are also low-profile jejunostomy devices (LPJDs) that are placed via a gastric stoma; the distal end is positioned in the small intestine via passage through the pylorus. These devices have the same advantages as the LPGDs described previously. (Hinkle 1252-1253) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Other parenteral nutrition facts

A total of 1 to 3 L of solution is given over a 24-hour period. The label of the solution is verified with the prescription. Intravenous fat emulsions (IVFEs or lipids) may be infused simultaneously with PN through a Y connector close to the infusion site and should not be filtered. The PN solution is not to be piggybacked into the IVFE. Usually, 500 mL of a 10% IVFE or 250 mL of 20% IVFE is given over 6 to 12 hours, one to three times a week. IVFEs can provide up to 30% of the total daily calorie intake. Quality and Safety Nursing Alert Before PN infusion is given, the solution must be inspected for separation, oily appearance (also known as a "cracked solution"), or any precipitate (which appears as white crystals). If any of these are present, it is not used. IVFEs can be mixed by the pharmacy staff with other components of PN to create a "three-in-one solution" commonly called a total nutrient admixture (TNA). Whereas a filter is not used with IVFE, a special final filter (1.2 micron filter) is used with TNA to prevent the administration of a precipitate (i.e., calcium, phosphorus, incompatibilities) that cannot be seen due to the opacity of the solution. Advantages of TNA over PN are cost savings in preparation and equipment, decreased risk of catheter or nutrient contamination, decreased nursing time, and increased patient convenience and satisfaction (Gervasio, 2015). Ideally, the pharmacist, nutritionist, and primary provider should collaborate to determine the specific formula needed. Initiating Therapy PN solutions are initiated slowly and advanced gradually each day to the desired rate as the patient's fluid and dextrose tolerance permits. The patient's laboratory test results and response to PN therapy are monitored on an ongoing basis by the primary provider. Standing orders are initiated for weighing the patient; monitoring I&O and blood glucose; and baseline and periodic monitoring of complete blood count, platelet count, and chemistry panel, including serum carbon dioxide, magnesium, phosphorus, and triglycerides. A 24-hour urine nitrogen determination may be performed for analysis of nitrogen balance. In most hospitals, the PN solutions are prescribed on a daily standard PN order form. The formulation of the PN solutions is calculated carefully each day to meet the complete nutritional needs of the individual patient. Administration Methods Various vascular access devices are used to administer PN solutions in clinical practice. PN may be given through either peripheral or central IV lines, depending on the patient's condition and the anticipated length of therapy. An infusion pump is always used for administration of PN. Peripheral Method To supplement oral intake, peripheral parenteral nutrition (PPN) may be prescribed. PPN is given through a peripheral vein; this is possible because the solution is less hypertonic than a full-calorie PN solution. PPN formulas are not nutritionally complete because of their low dextrose content. Lipids are given simultaneously to buffer the PPN and to protect the peripheral vein from irritation. The usual length of therapy using PPN is 5 to 7 days. Quality and Safety Nursing Alert Formulations with dextrose concentrations of more than 10% should not be given through peripheral veins because they irritate the intima (innermost walls) of small veins, causing chemical phlebitis. Central Method Because central parenteral nutrition (CPN) solutions have five or six times the solute concentration of blood (and exert an osmotic pressure of about 2,000 mOsm/L), they are given into the vascular system through a catheter inserted into a high-flow, large blood vessel (e.g., ideally at the superior vena cava/right atriocaval junction). Concentrated solutions are then very rapidly diluted to isotonic levels by the blood in this vessel. Several types of central venous access device (CVADs) are available: percutaneous (or nontunneled), peripherally inserted central catheters (PICCs), surgically placed (or tunneled) catheters, and implanted vascular access ports. Percutaneous (Nontunneled) Central Catheters Percutaneous central catheters are used for short-term (less than 6 weeks) IV therapy in acute care settings. The subclavian vein is the most common vessel accessed because the subclavian area provides a stable insertion site to which the catheter can be anchored, is easily compressible (facilitating control of hemorrhage), allows the patient freedom of movement, and provides easy access to the dressing site. The subclavian access site should be avoided in patients with advanced kidney disease and those on hemodialysis to prevent subclavian vein stenosis. The second most common access sites include the basilic, brachial, or cephalic veins in the arm followed by the jugular vein. The femoral vein should be avoided for this purpose and should only be used as a last resort because of concerns about infection (Gorski, Hadaway, Hagle, et al., 2016). For a patient with limited IV access, a triple-lumen catheter can be used because it offers three ports for various uses (see Fig. 44-6). The use of a single-lumen catheter dedicated for the administration of PN is not typically feasible, because most patients require administration of medications and fluids in addition to PN, and the line used to administer PN cannot be used for other purposes. Figure 44-6 • Subclavian triple-lumen catheter used for parenteral nutrition and other adjunctive therapy. The catheter is threaded through the subclavian vein into the vena cava/right atriocaval junction. Each lumen is an avenue for solution administration. The lumens are secured with threaded needleless adapters or Luer lock-type caps when the device is not in use. When a patient requires IV access for PN, the insertion procedure is first explained so that the patient is aware of what to expect. The patient is placed supine in the Trendelenburg position to produce dilation of neck and shoulder vessels, which makes insertion easier and decreases the risk of air embolus. The skin is cleansed with 2% chlorhexidine to remove surface oils. To afford maximal accuracy in the placement of the catheter, the patient is instructed to turn their head away from the site of venipuncture and to remain motionless while the catheter is inserted and the wound is dressed. The nurse maintains the sterile field and supports the patient throughout the procedure. Maximal barrier precautions mandate that full-body sterile drapes are applied and sterile gloves, cap, gown, and masks are donned to reduce risk of central line-associated bloodstream infection (CLABSI) (Institute for Healthcare Improvement [IHI], 2012) (see Chapter 14, Chart 14-2). Lidocaine is injected to anesthetize the skin and underlying issues. A large-bore needle on a syringe is inserted and moved parallel to and beneath the clavicle until it enters the vein. A radiopaque wire is inserted through the needle into the vein. The catheter is then advanced over the wire, the needle is withdrawn, and the hub of the catheter is attached to the IV tubing. Until the syringe is detached from the needle and the catheter is inserted, the patient may be asked to perform the Valsalva maneuver. The patient is instructed to take a deep breath, hold it, and bear down with the mouth closed to produce a positive phase in central venous pressure, thereby lessening the possibility of air being drawn into the circulatory system (air embolism). The catheter is sutured to the skin. A chlorhexidine-impregnated disc or gel with a semipermeable transparent dressing is applied using strict sterile technique (Marschall, Mermel, Fakih, et al., 2014). The position of the tip of the catheter is verified with x-ray or fluoroscopy to confirm its location in the superior vena cava at the junction of the right atrium and to rule out a pneumothorax resulting from inadvertent puncture of the pleura. Once the catheter's position is confirmed, the prescribed CPN solution can be started. The initial rate of infusion is usually low, and the rate is gradually increased to the target rate. An injection cap is attached to the end of each central catheter lumen, creating a closed system. IV infusion tubing is connected to the insertion cap of the central catheter with a threaded needleless adapter or Luer lock device. To ensure patency, all lumens are initially flushed according to institution policy with a 10-mL syringe. Smaller volume syringes are not to be used because the pressure from smaller syringes is potentially harmful to the catheter. Lumens are flushed with normal saline or diluted heparin (10 U/mL) after each intermittent infusion and after blood drawing; this flushing is necessary daily when the catheter is not in use. Force is never used to flush the catheter (Gorski et al., 2016). If resistance is met, aspiration may restore lumen patency; if this is not effective, the primary provider is notified. Low-dose tissue plasminogen activator may be prescribed to dissolve a clot or fibrin sheath. If attempts to clear the lumen are ineffective, the catheter should be changed. Peripherally Inserted Central Catheters Central Venous Access Devices: Assessing a Peripherally Inserted Central Catheter (PICC) Site video Click to Show Peripherally inserted central catheters (PICCs) are used for intermediate-term (several days to months) IV therapy in the hospital, long-term care, or home setting. These catheters may be inserted at the bedside or in the outpatient setting by a primary provider or specially trained nurse. The basilic, brachial, or cephalic vein is accessed above the antecubital space, and the catheter is threaded to the superior vena cava/right atriocaval junction (see Chapter 15, Fig. 15-6). Taking of blood pressure and blood specimens from the extremity with the PICC is avoided. Surgically Placed (Tunneled) Central Catheters Surgically placed central catheters are for long-term use and may remain in place for many years. These catheters are cuffed and can have single or double lumens; examples are the Power line (Power injectable), Hickman, Groshong, and Permacath. These catheters are inserted surgically. They are threaded (or tunneled) under the skin (reducing the risk of ascending infection) to the subclavian vein and advanced into the superior vena cava. p. 1258 p. 1259 Implanted Vascular Access Ports Central Venous Access Devices: Accessing an Implanted Port video Click to Show Implanted vascular access ports are also used for long-term IV therapy; examples include the Power injectable Port-A-Cath, Mediport, Hickman Port, and P.A.S. Port. Instead of exiting from the skin, the end of the catheter is attached to a small chamber that is placed in a subcutaneous pocket, either on the anterior chest wall or on the forearm. The port requires minimal care and allows the patient complete freedom of activity. Implanted ports are more expensive than the external catheters, and access requires passing a special noncoring needle (Huber tipped) through the skin into the chamber to initiate IV therapy (see Chapter 15, Fig. 15-5). Discontinuing Parenteral Nutrition The PN solution is discontinued gradually to allow the patient to adjust to decreased levels of glucose. If the PN solution is abruptly terminated, isotonic dextrose can be given at the same rate the PN solution was infusing for 1 to 2 hours to prevent rebound hypoglycemia. Symptoms of rebound hypoglycemia include weakness, faintness, sweating, shakiness, feeling cold, confusion, and increased heart rate. Once IV therapy is completed, the percutaneous central venous catheter or PICC is removed, pressure is held until hemostasis is achieved, and an occlusive dressing is applied to the exit site. Surgically placed central catheters and implanted vascular access ports are removed only by the primary provider. (Hinkle 1257-1259) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Gastric tubes for decompression and drainage

A variety of tubes are used for decompression, drainage, aspiration (removal of substances by suction), and lavage of the stomach. Gastric tubes may also be labeled by their point of origin and end points. For instance, an orogastric tube is a large-bore tube inserted through the mouth into the stomach that contains a wide outlet for removal of gastric contents. Gastric tubes, commonly called nasogastric (NG) tubes, are introduced through the nose into the stomach, often before or during surgery or at the bedside, to remove fluid and gas from the upper GI tract by the process known as decompression (gastric/intestinal). Other tubes, such as the Sengstaken-Blakemore and the Minnesota tube, are used to treat bleeding esophageal varices (see Chapter 49). Commonly used gastric tubes include the Levin and the Salem Sump tube (see Table 44-1). Levin Tube The Levin tube has a single lumen (channel within a tube or catheter) and is made of plastic or rubber. This tube is connected to low intermittent suction (30 to 40 mmHg) to avoid erosion or tearing of the stomach lining, which can result from adherence of the tube's lumen to the mucosa of the stomach. If this type of tube is removed inadvertently in a patient who has undergone esophageal or gastric surgery, it is usually replaced by the surgeon with care to avoid trauma to the suture line. Salem Sump The Salem Sump tube is a radiopaque (easily seen on x-ray), clear plastic, double-lumen gastric tube. The inner, smaller lumen (known as the blue port) vents the larger suction-drainage tube to the atmosphere by means of an opening at the distal end of the tube. The sump tube can protect fragile gastric mucosa by maintaining a low (25 mmHg) continuous force of suction at the drainage opening. The suction lumen may be irrigated to maintain patency. The blue vent lumen should be kept above the patient's waist to prevent reflux of gastric contents through it; otherwise, it acts as a siphon. A one-way antireflux valve (prevents return or backward flow of fluid) seated in the blue pigtail can prevent the reflux of gastric contents out the vent lumen (see Fig. 44-1). The valve is removed for irrigation of the suction lumen. To reestablish a buffer of air between the gastric contents and the valve, 20 mL of air is injected through the blue vent with a catheter tip syringe and the valve is reinserted. Nursing Management Nutrition: Inserting a Nasogastric Tube video Click to Show The nurse explains the purpose of the tube to the patient prior to insertion to promote cooperation during the procedure. The general activities related to inserting the tube are then reviewed, including the fact that the procedure may cause gagging until the tube has passed beyond the throat. Periodically, the gastric tube's placement must be verified. (Hinkle 1244) Gastric tubes used for decompression and drainage are connected to a wall mounted suction regulator and canister or to a suction machine. It is the nurse's responsibility to ensure that the suction is set at the prescribed pressure. Drainage should be assessed and noted as consistent with gastric drainage. Sterile saline or water can be used as irrigants, if prescribed and as needed, to keep the system patent. The nurse records the amount, color, and type of drainage. The nurse must ensure that oral and nasal hygiene are maintained to prevent discomfort, skin breakdown, and infection (see later discussion under feeding tubes: Providing Oral and Nasal Hygiene). When the gastric tube may be removed, the nurse explains the procedure to the patient and assesses for nausea and distention, delaying removal and notifying the primary provider if these are present. (Hinkle 1245) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Gastrointestinal intubation.

GI intubation is the insertion of a flexible tube into the stomach, or beyond the pylorus into the duodenum (the first section of the small intestine) or the jejunum (the second section of the small intestine). The tube may be inserted through the mouth, the nose, or the abdominal wall. The tubes are of various diameters (French [Fr] size) and lengths, depending on their intended use. GI intubation may be performed in order to: Decompress the stomach and remove gas and fluid Lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials Diagnose GI disorders Administer tube feedings, fluids, and medications Compress a bleeding site Aspirate GI contents for analysis (Hinkle 1244) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Parenteral nutrition

Parenteral nutrition (PN) is a method of providing nutrients to the body by an IV route. The nutrients are a complex admixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water in a single container. The goals of PN are similar to the goals of enteral feedings; namely, to improve nutritional status, establish a positive nitrogen balance, maintain muscle mass, promote weight maintenance or gain, and enhance the healing process (Seres, 2016). Establishing Positive Nitrogen Balance Most IV fluids do not provide sufficient calories or protein to meet the body's daily requirements. PN solutions can provide enough calories and nitrogen to meet the patient's daily nutritional needs. The patient with fever, trauma, burns, major surgery, or hypermetabolic disease requires additional daily calories (Gauglitz, 2014). When highly concentrated dextrose is given, caloric requirements are satisfied and the body uses amino acids for protein synthesis rather than for energy. Additionally, electrolytes such as calcium, phosphorus, magnesium, and sodium chloride are added to the solution to maintain proper electrolyte balance and to transport glucose and amino acids across cell membranes. The volume of fluid necessary to provide these calories peripherally can surpass fluid tolerance. To provide the required calories in a smaller volume, it is necessary to increase the concentration of nutrients and use a route of administration that rapidly dilutes incoming nutrients to the proper levels of body tolerance. Typically, a large, high-flow vein such as the superior vena cava (at the right atriocaval junction) is the preferred site. Clinical Indications The indications for PN include an inability to ingest adequate oral food or fluids within a 7- to 10-day timeframe (McClave et al., 2016). Enteral nutrition should be considered before parenteral support because it assists in maintaining gut mucosal integrity and improved immune function and is typically associated with fewer complications. In both the home and hospital setting, PN is indicated in the situations listed in Table 44-4. (Hinkle 1256) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Giving medications and maintaining delivery systems

Providing Medications by Tube When different types of medications are prescribed, a bolus method is used for administration that is compatible with the medication's preparation. The tube is flushed with 30 mL of water before and after medication administration, and this is recorded as intake. When small-bore feeding tubes for continuous infusion are irrigated after administration of medications, a 30-mL or larger syringe is used because the pressure generated by smaller syringes could rupture the tube. Quality and Safety Nursing Alert Administering medications through postpyloric enteric tubes may adversely affect their absorption; therefore, this should be avoided if possible. In addition, to avoid nutrient and drug interactions, medications should not be mixed with the feeding formulas. Maintaining Delivery Systems Tube feeding formula is delivered to patients by either an open or a closed system. The open system is packaged as a liquid or a powder to be mixed with water that is either poured into a feeding container or given by a large syringe. The feeding container (which is hung on a pole) and the tubing used with the open system should be changed every 24 hours (Bankhead et al., 2009). The open system can be used for bolus feedings, intermittent feedings, or continuous drip feedings and can be delivered by push (with a syringe and plunger), gravity (syringe with plunger removed or gravity bag with roller clamp), or pump. To avoid bacterial contamination, the formula hang time in the bag at room temperature should never exceed what the formula manufacturer recommends, which is usually no more than 4 to 8 hours. Closed delivery systems use a prefilled, sterile container of about 1 L of formula that is spiked with enteral tubing and allows a hang time of 24 to 48 hours at room temperature. The closed delivery system must always use a pump to control formula rate in order to avoid dispensing a large formula volume in a short period of time. (Hinkle 1250) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Indications for parenteral nutrition

TABLE 44-4 Indications for Parenteral Nutrition Condition or Need Examples Insufficient oral or enteral intake Severe burns, malnutrition, short-bowel syndrome, acquired immune deficiency syndrome, sepsis, cancer Impaired ability to ingest or absorb food orally or enterally Paralytic ileus, Crohn's disease, short-bowel syndrome, postradiation enteritis, high-output enterocutaneous fistula Patient unwilling or unable to ingest adequate nutrients orally or enterally Major psychiatric illness (e.g., severe anorexia nervosa) Prolonged preoperative and postoperative nutritional needs Extensive bowel surgery, acute pancreatitis (Hinkle 1257) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Formulas

The choice of formula to be delivered by tube feeding is influenced by the status of the GI tract and the nutritional needs of the patient. Formula characteristics that are considered include the chemical composition of the nutrient source (protein, carbohydrates, fat), caloric density, osmolality, fiber content, vitamins, minerals, electrolytes, and cost. Enteral formulas contain 70% to 85% free water and are not designed to meet total fluids needs (Seres, 2016). A wide variety of containers, delivery systems, and enteral pumps are available for use with tube feedings. Various tube feeding formulas are available commercially. Polymeric formulas are the most common; are composed of protein, carbohydrates, and fats in a high-molecular-weight form, and require that the patient has normal digestive function. Chemically defined or "predigested" formulas contain easier-to-absorb nutrients. Modular products contain only one major nutrient, such as protein, and are used to enhance commercially prepared products. Disease-specific formulas are available as adjuncts to treat various conditions. Fiber, either premixed in or added to formulas, helps bulk the stool to decrease the occurrence of both diarrhea and constipation (McClave et al., 2016). Some feedings are given as supplements, and others are given to meet the patient's total nutritional needs. Dietitians and certified nutrition support clinicians collaborate with primary providers and nurses to determine the best formula for each patient. The volume of formula delivered varies depending on the caloric density of the formula and the energy needs of the patient. The overall goal is to achieve positive nitrogen balance and weight maintenance or gain without producing discomfort or diarrhea. (Hinkle 1248-1249) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Osmalility

The osmolality of normal body fluids (i.e., ionic concentration) is approximately 300 mOsm/kg. The body attempts to keep the osmolality of the contents of the stomach and intestines at this level. Osmolality is an important consideration for patients receiving tube feedings through the duodenum or jejunum because feeding formulas with a high osmolality may lead to undesirable effects. For example, when a concentrated solution of high osmolality entering the intestines is taken in quickly or in large amounts, water moves rapidly into the intestinal lumen from fluid surrounding the organs and the vascular compartment. The patient may have feelings of fullness, nausea, cramping, dizziness, diaphoresis, and osmotic diarrhea, collectively termed dumping syndrome. This can lead to dehydration, hypotension, and tachycardia. Patients fed by the small intestinal route vary in the degree to which they tolerate the effects of high osmolality; the nurse needs to be knowledgeable about the patient's formula and take steps to prevent this undesired effect. The small intestines may be able to adapt to a formula of high osmolality if it is initiated at a low hourly rate that is advanced slowly (Seres, 2016). (Hinkle 1248) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.

Administering tube feedings

Tube feedings are given to meet nutritional requirements when oral intake is inadequate or not possible and the GI tract is functional. The feedings are delivered to the stomach, duodenum, or proximal jejunum and help preserve GI integrity by preserving normal intestinal and hepatic metabolism. Tube feedings have several advantages over parenteral nutrition (PN): they are lower in cost, safer, usually well tolerated by the patient, and easier to use in extended-care facilities and in the patient's home. Nasoduodenal or nasojejunal feeding is indicated when the esophagus and stomach need to be bypassed or when the patient is at risk for aspiration. For tube feedings longer than 4 weeks, gastrostomy or jejunostomy tubes are preferred for administration of medications or nutrition. Indications for enteral nutrition are summarized in Table 44-2. (Hinkle 1247) Hinkle, Janice L., Kerry Cheever. Lippincott's CoursePoint for Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th Edition. CoursePoint, 10/2017. VitalBook file.