FU enteral feeding and bowels

Diarrhea

Etiology and pathophysiology Infection Lack of bowel flora Clinical manifestations Diagnostic studies Culture Occult Blood Collaborative care antibiotics cause d/ bc clears out normal flora = good bacteria

Constipation

Medications - narcotics Lack of Bowel motility - sedintary life style Poor nutrition - need fluids Clinical manifestations - abd pain, distention, tender, bloating Diagnostic studies and collaborative care Nutritional therapy Fluids and fiber

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An ongoing evaluation measures the value of your activities in meeting a patient's nutritional needs. Allow enough time to test a nursing approach to a problem because nutritional improvement takes time. Evaluation of clinical progress includes objective data such as weight gain or improved laboratory parameters or subjective data such as a patient reporting improvement in food choices or self-reporting improved intake. If outcomes are not met, reassess the patient to determine if you missed any important data. [Box 33-12 in the textbook provides an example of evaluation.] Nutritional interventions often depend on a patient's willingness and ability to change behavior patterns and learn new patterns. If a patient is not fully committed to the expected changes, the interventions will not always be successful. Some patients also find it difficult to change behavior and are less motivated with the passage of time. It is important to remember to individualize the nutrition care plan and focus on the patient. Most patients respond well to the opportunity to make informed choices. Explaining the reasons for the behavioral change and providing the patient options for how to achieve the change can help him or her achieve success. If necessary provide education in several brief sessions to maximize the retention of information.

eating disorders

Anorexia nervosa - malnourished, psych, depressive state, eating less than 85% of what they need to be taking in, alters hormones bc no fat, no periods = after 3 months Bulimia nervosa - binge eating and purging, laxatives, extra exercise, cardiac arrest, fluid and electrolytes, Binge-eating disorder - newer, episodes, large amount of food intake

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At times following abdominal or pelvic surgery an ileus or temporary cessation of peristalsis occurs. A patient cannot eat or drink fluids without causing abdominal distention and nausea and vomiting to occur. The insertion of a nasogastric (NG) tube into the stomach serves to decompress the stomach, keeping it empty until normal peristalsis returns. Nasogastric tube insertion does not require sterile technique. Clean technique is adequate. One of the greatest nursing care challenges is keeping the patient comfortable because the tube is a constant irritation to mucosa. Routinely assess the condition of the nares and mucosa for inflammation and excoriation. [Skill 35-1 in the textbook details inserting and maintaining a nasogastric tube for gastric decompression.] An enema is an instillation of a solution into the rectum and sigmoid colon. It is given primarily to promote defecation by stimulating peristalsis. The volume of fluid instilled breaks up the fecal mass, stretches the rectal wall, and begins the defecation reflex. Enemas are also a vehicle for drugs that exert a local effect on rectal mucosa. The most common use for an enema is temporary relief of constipation. Other indications include removing impacted feces, emptying the bowel before diagnostic tests, some surgical procedures, and beginning a program of bowel training. A health care provider sometimes orders a high or low cleansing enema. The terms high and low refer to the height and pressure with which you deliver the fluid. You give high enemas to clean the entire colon. A low enema cleans only the rectum and sigmoid colon. [Skill 35-2 in the textbook outlines the steps for enema administration.] For patients with an impaction, the fecal mass is sometimes too large for the patient to pass voluntarily. If enemas fail, the mass needs to be broken up digitally. Patients with an impaction frequently have a continuous oozing of liquid stool because liquid passes around the impacted feces. This procedure is done only when all other measures have failed. Before you perform the procedure, check your agency policy regarding a health care provider's order. [Review Box 35-11, Procedural Guidelines: Digital Removal of Stool.] [Shown is Figure 35-11, Prepackaged enema container with rectal tip.]

BRAT, BRATT, BRATY, BRATTY, CRAM

BRAT Bananas, Rice, Applesauce, Toast BRATT Bananas, Rice, Applesauce, Toast, Tea BRATY Bananas, Rice, Applesauce, Toast, Yogurt BRATTY Bananas, Rice, Applesauce, Toast, Tea, Yogurt CRAM Cereal, Rice, Applesauce, Milk

Restorative Care

Bowel training An individualized program to promote normal defecation Daily routine Ostomy care Special equipment Requires pouches and skin barriers Hemorrhoid care Fluids, diet, and regular exercise are needed Skin integrity Mild soap and water after passage of each stool Barrier ointment

Diagnostic Test

CT Scan MRI Colonscopy Nursing responsiblilities Barium Swallow Barium Enema Occult Blood Stool Culture

Nutrients: The Biochemical Units of Nutrition

Carbohydrates Complex and simple saccharides Main source of energy mono = simple carbs (starches) poly = complex (sugars) Proteins Amino acids Necessary for nitrogen balance, building repair body tissue Fats Saturated (animals), polyunsaturated (veggie), and monounsaturated (oils liquid at room temp) Calorie-dense

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Carbohydrates, composed of carbon, hydrogen, and oxygen, are the main source of energy in the diet. Each gram of carbohydrate produces 4 kcal/g and serves as the main source of fuel (glucose) for the brain, skeletal muscles during exercise, erythrocyte and leukocyte production, and cell function of the renal medulla. You obtain carbohydrates primarily from plant foods, except for lactose (milk sugar). Carbohydrate classification occurs according to their carbohydrate units, or saccharides. Monosaccharides such as glucose (dextrose) or fructose do not break down into a more basic carbohydrate unit. Disaccharides such as sucrose, lactose, and maltose are composed of two monosaccharides and water. The classification of both monosaccharides and disaccharides is as simple carbohydrates; found primarily in sugars. Polysaccharides such as glycogen make up carbohydrate units too (i.e., complex carbohydrates). They are insoluble in water and digested to varying degrees. Starches are polysaccharides. The body is unable to digest some polysaccharides because we do not have enzymes capable of breaking them down. Fiber, a polysaccharide, is the structural part of plants that is not broken down by our digestive enzymes. The inability to break down fiber means it does not contribute calories to the diet. Therefore, insoluble fibers are not digestible and include cellulose, hemicellulose, and lignin. Soluble fibers dissolve in water and include barley, cereal grains, cornmeal, and oats. Proteins provide a source of energy (4 kcal/g), and they are essential for the growth, maintenance and repair of body tissue. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein. In addition, blood clotting, fluid regulation, and acid-base balance require proteins. Proteins transport nutrients and many drugs in the blood. Ingestion of proteins maintains nitrogen balance. The simplest form of protein is the amino acid, consisting of hydrogen, oxygen, carbon, and nitrogen. Because the body does not synthesize indispensable amino acids we need these to be provided in our diet. The body synthesizes dispensable amino acids. Examples of amino acids synthesized in the body are alanine, asparagine, and glutamic acid. Amino acids can link together. Albumin and insulin are simple proteins because they contain only amino acids or their derivatives. The combination of a simple protein with a nonprotein substance produces a complex protein such as lipoprotein, formed by a combination of a lipid and a simple protein. A complete protein, also called a high-quality protein, contains all essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. Incomplete proteins are missing one or more of the nine indispensable amino acids and include cereals, legumes (beans, peas), and vegetables. Complementary proteins are pairs of incomplete proteins that, when combined, supply the total amount of protein provided by complete protein sources. Achieving nitrogen balance means that the intake and output of nitrogen are equal. When the intake of nitrogen is greater than the output, the body is in positive nitrogen balance. Positive nitrogen balance is required for growth, normal pregnancy, maintenance of lean muscle mass and vital organs, and wound healing. The body uses nitrogen to build, repair, and replace body tissues. Negative nitrogen balance occurs when the body loses more nitrogen than it gains (e.g., with infection, burns, fever, starvation, head injury, and trauma). The increased nitrogen loss is the result of body tissue destruction or loss of nitrogen-containing body fluids. Nutrition during this period needs to provide nutrients to put patients into positive balance for healing. Protein provides energy but, because its essential role is to growth, maintenance, and repair, a diet needs to provide adequate kilocalories from nonprotein sources. When there is sufficient carbohydrate in the diet to meet the body's energy needs, protein is spared as an energy source. Fats (lipids) are the most calorie-dense nutrient, providing 9 kcal/g. Fats are composed of triglycerides and fatty acids. Triglycerides circulate in the blood and are composed of three fatty acids attached to a glycerol. Fatty acids are composed of chains of carbon and hydrogen atoms with an acid group on one end of the chain and a methyl group at the other. Fatty acids can be saturated, in which each carbon in the chain has two attached hydrogen atoms; or unsaturated, in which an unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond. Monounsaturated fatty acids have one double bond, whereas polyunsaturated fatty acids have two or more double carbon bonds. The various types of fatty acids, referred to in the dietary guidelines have significance for health and the incidence of disease. We also classify fatty acids as essential or nonessential. Linoleic acid, an unsaturated fatty acid, is the only essential fatty acid in humans. Linolenic acid and arachidonic acid, another type of unsaturated fatty acids, are important for metabolic processes. The body manufactures them when linoleic acid is available. Deficiency occurs when fat intake falls below 10% of daily nutrition. Most animal fats have high proportions of saturated fatty acids, whereas vegetable fats have higher amounts of unsaturated and polyunsaturated fatty acids.

Medication Usage

Cathartics and laxatives Stimulants Saline or osmotic agents Wetting agents or stool softeners Bulk forming Lubricants

Feces

Color Black or tarry - blood in stool or taking iron Red - lower GI bleed, hemorrhoids, eating beets Consistency Soft, formed, liquid, hard Odor Frequency Amount

Nursing Knowledge Base: Bowel Elimination Problems

Constipation A symptom, not a disease; fewer than three bowel movements per week, >25% of which are hard and require straining to evacuate Diarrhea an increase in the number of stools and the passage of liquid, unformed feces Flatulence Accumulation of gas in the intestines causing the walls to stretch Impaction Results from unrelieved constipation; a collection of hardened feces that a person cannot expel Fecal Incontinence Inability to control passage of feces and gas to the anus Hemorrhoids Dilated, engorged veins in the lining of the rectum

Geriatric Considerations

Decreased bowel tone = increased risk for constipation and fecal impaction Less able to compensate for fluid loss due to diarrhea

Health Promotion Activities

Diet Low fat, increase fiber and bulk-forming foods Maintain fluid intake. Exercise Age specific 30 minutes a day Timing and privacy Make time to defecate; usually 1 hour after meals. Promotion of normal defecation Assume a normal squatting position, which facilitates the use of intraabdominal muscles.

Restorative and Continuing Care

Diet therapy in disease management Medical nutrition therapy (refer to Nutrition Class) Home care Education Assessment Troubleshooting and problem prevention Help patient transition to oral intake when indicated

Interventions for Those Unable to Meet Nutritional Needs Orally (Cont.)

Enteral tube feedings Jejunostomy tubes and tube feedings Displacement

Fecal Incontinence

Etiology and pathophysiology Diagnostic studies and collaborative care elderly - cog, can't make it, sphincter relaxation

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During planning you select nursing interventions intended to improve a patient's nutritional status and the monitoring and evaluation to determine the effectiveness of those interventions. Individualize all intervention to the patient's needs and take into consideration his or her comfort and preferences. Although variables exist between and among patients, common nutritional goals include symptom management, weight maintenance, and preservation of functional status. The goal in caring for patients with nutritional alterations is to improve their nutritional status. Determine specific, individualized goals by identifying patient behaviors that have led to the nutritional alteration. Correction of poor dietary patterns is a long-term rather than a short-term goal. Short-term goals usually involve achieving calorie or nutrient targets on a daily or weekly basis. Goals are achieved through a prescribed diet, patient education, and helping a patient develop new behaviors that will enable him or her to achieve an adequate nutritional status. [Review Care Plan: Nutrition in the textbook.] Food is important for all people; but, when illness disrupts appetite or the ability to eat, anticipate what is most important to help your patient achieve good nutrition. The development of the care plan requires collaboration of the health care team, the patient, and the family caregivers. Professionals who help provide care include the RD, nutritional support clinical nurse specialist, pharmacists, and medical health care providers.

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Ensuring patient safety is an essential role of a professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient's priorities of care and preferences, and use the best evidence when making decisions about your patient's care. When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care: Label enteral equipment with patient name, room number, formula name, rate, date and time of initiation, and nurse initials (Bankhead et al., 2009). Ensure "right patient, right formula, right tube" by matching formula and rate to feeding order and verifying that enteral tubing set connects formula to feeding tube (Bankhead et al., 2009). Elevate the head of the bed a minimum of 30 to 45 degrees unless medically contraindicated for patients receiving enteral feedings (Metheny and Frantz, 2013). Trace all lines and tubing back to patient to ensure that you have only enteral-to-enteral connections (Bankhead et al., 2009; Guenter et al., 2008). Monitoring tube placement is essential in early detection of tube misplacement. Auscultation is not a reliable method for verification of NG or nasointestinal tube placement because a tube inadvertently placed in the lungs, pharynx, or esophagus also transmits a sound similar to that of air entering the stomach (Proehl et al., 2011; Simmons and Abdallah, 2012).

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Enteral nutrition (EN) refers to administration of nutrients and fluid into the stomach or intestinal tract via a feeding tube. NG feedings are delivered through a feeding tube introduced through the nose and into the stomach. Nasointestinal feedings are delivered through a feeding tube inserted through the nose and into the small intestine (duodenum or jejunum). When patients have nasopharyngeal obstructions or are not candidates for nasally placed tubes or when the need for EN is anticipated to be longer than several weeks, feeding tubes may be inserted directly into the stomach (gastrostomy) or jejunum (jejunostomy). [Table 33-5 in the textbook compares enteral feeding tubes.] A variety of enteral feeding formulas are available to meet patient needs. When a patient cannot safely swallow food or take adequate amounts of food orally but can digest and absorb nutrients, a small-bore feeding tube is placed nasally into the stomach or small intestine [Skill 33-2 in the textbook describes insertion of a small-bore feeding tube.] When making the decision regarding enteral access, the health care provider considers the patient's rate of gastric emptying, GI anatomy, risk for gastric reflux and aspiration, anticipated duration of requirement for enteral access, and disease state. Ensure that enteral feedings are correctly connected to an enteral feeding tube. The gold standard for determining tube location is radiographic confirmation. Assessing the color and pH of gastric aspirate for ongoing monitoring of tube location has been shown to be effective and less costly. [Box 33-9 in the textbook provides evidence-based practice information related to enteral tube feeding.] [Review Box 33-10: Procedural Guidelines: Verifying Enteral Tube Placement by Obtaining Gastrointestinal Aspirate for pH Measurement via Large-Bore and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding.] When patients cannot tolerate nasally or orally placed tubes or when EN is anticipated to be needed for more than several weeks, tubes may be placed percutaneously into the GI tract through the abdomen. A surgeon inserts a G-tube through a small incision in the left upper quadrant of the stomach either laparoscopically or with an open surgical technique. This type of feeding tube is held in place internally by a balloon, pigtail design, or other design. A G-tube may also be placed with an endoscope and is also called a percutaneous endoscopic gastrostomy (PEG) tube. A PEG tube is held in place because of its design. [Shown is Figure 33-5, Percutaneous endoscopic gastrostomy tube.] You administer feedings into the stomach via a G-tube using gravity bolus in small volumes or continuously by a slow infusion. Because gastrostomy tubes (G-tubes) permit more options for feeding delivery and thus more freedom and flexibility for patients, they should be considered for longer-term feeding instead of jejunal tubes whenever possible.

Interventions for Those Unable to Meet Nutritional Needs Orally

Enteral tube feedings Feeding tube insertion Gastrostomy tubes and tube feedings Initial position confirmed with X-ray Do not crush enteric coating or pebbles or XR into the tubes minim swallowing or swallow water to get tube down

ATI: Dietary Requirements

Fiber: 25 to 30 g/day Fluid: 2 to 3 L/day from fluid and food sources

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Following nursing assessment, cluster relevant defining characteristics to determine whether actual or potential nutritional problems exist. An alteration occurs when the body does not ingest a nutrient in sufficient quantity, when it poorly digests or does not completely absorb nutrients, or when total daily caloric needs are deficient or excessive. Examples of nursing diagnoses appropriate for patients with nutritional alterations are shown on the slide. During your assessment, identify the probable cause or related factor for the nutritional problem. Make sure that the nursing diagnosis is as precise as possible. Related factors need to be accurate so you will select the appropriate interventions. [See Figure 33-3, Concept map in the textbook for an example of a concept map that includes dysphagia.]

Nursing Process: Planning

Goals and outcomes Goals: Improve nutritional status. May be short term or long term. Setting priorities Anticipate what is most important to help your patient achieve good nutrition. Collaborative care Patient, family Professionals

Assessments

Health history Physical assessment Laboratory Diagnostic tests

Nursing Process: Implementation

Health promotion Meal planning Education Weight loss plans Food safety

Providing Parenteral Nutrition

Increased risk of infection Solution is formulated to each patient's needs Need for PN is evaluated daily Central PN PN solutions that contain 10% dextrose or greater Administered through a central venous catheter Peripheral PN PN solutions with osmolality <900 mOsm Administered through peripheral veins infection from basically getting sugar into veins = more diluted pharmacy makes it all tube feedings changed ever 24 hours

Providing Parenteral Nutrition (Cont.)

Initiating PN Patient care clean off everytime Preventing infection Maintaining the PN system Preventing complications Meeting nutritional and fluid needs Evaluating continued need for PN Planning for home PN Providing support once a port is used for feeding, cant be used for anything else no matter what, gets special sticker

Enemas

Instillation into the rectum and sigmoid colon Cleansing - promotes complete evacuation of feces. Stimulates peristalsis Tap water, hypertonic saline, soapsuds Tap water (hypotonic) Some water enters interstitial space. Do not repeat for danger of water toxicity Hypertonic (fleet) exerts osmotic pressure and pulls fluid out of interstitial space into bowel Soap solution (castile soap) only all others cause inflammation. Castile causes irritation Oil retention - lubricates the rectum and colon. Feces absorbs oil and becomes softer

Diagnostic Tests

KUB Lower GI - Barium Enema Colonoscopy - prep Stool Culture Occult Blood

Safety Guidelines

Label enteral equipment. Ensure "right patient, right formula, right tube" Elevate the head of the bed a minimum of 30 to 45 degrees. Trace all lines and tubing back to patient. Monitor tube placement. Aspirate prior to intermittent feedings. Aspirate every 4 hours for continuous feeding every 4-6 check tube placement every 24 hrs change tubing Hold feeding for residual of 500 ml or more Return aspirate to stomach If greater than 250 ml consult with agency policy Flush tubing with 30 ml of water every 4 hours. Flush prior to and after medication administration Monitor Blood glucose every 6 hours (finger stick)

Ostomies

Loop - emergency Temporary in the transverse colon End Proximal end forms stoma and distal end is removed or sewn closed Double-barrel Bowel is surgically severed and both ends are brought through the abdomen still have BM but will be mucus

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Many types of pouches and skin barriers are available. Some pouches have skin barriers attached and are one-piece pouching systems (shown on left). Some of these one-piece pouches already are precut to size by the manufacturer, whereas others you custom cut to size for the patient's stoma measurement. Other systems have two separate pieces (shown on right). Attach the pouch to the skin barrier by attaching it to the flange (a plastic ring) on the barrier. Often you have to custom cut the skin barrier to the patient's specific stoma size. For two-piece systems use the skin barrier with flange corresponding to the size of the ring on the pouch, making sure that both pieces are from the same manufacturer. Understand how to use each of these different pouching systems before attempting to teach ostomy care to the patient. If possible, change the pouch when the stoma is less active, usually before meals. Have the patient participate in the procedure as much as possible. The patient needs to learn to recognize the normal appearance of a stoma. [Skill 35-3 in the textbook describes the steps for pouching an ostomy.] [Shown on left is Figure 35-9, One-piece pouch with Velcro closure. (Courtesy Coloplast, Minneapolis, MN)] [Shown on right is Figure 35-10, Two-piece pouching system with separate skin barrier and attachable pouch. (Courtesy Coloplast, Minneapolis, MN)]

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Matt also discusses the importance of compliance with diet modifications until swallowing function returns completely. [Ask the class: What would Matt write in a documentation note?] A sample documentation note is: Patient and family educated on patient illness and interventions to improve motor function and independence. Feeding tube in use until patient is rehabilitated. SLP working with patient to improve communication skills.

Case Study

Matt is a nursing student assigned to Mrs. Gonzales. As he prepares to assess her, he recalls information about the effects of dysphagia on nutrition and rehabilitation. He will assess Mrs. Gonzales' weight, weight history, diet history, and cultural customs. Matt knows to consult with a registered dietitian (RD) to assess Mrs. Gonzales' nutritional status and interventions. Mrs. Gonzales will have a small-bore nasogastric feeding tube and starting her tube feedings. The RD has recommended continuous tube feeding for 12 hours during the day. To provide proper care of Mrs. Gonzales, Matt needs to assess her weight, weight history, diet history, and cultural customs. Diagnosis: Risk for Aspiration Goals: Mrs. Gonzales will receive adequate nutrients through enteral tube feeding without aspiration by the time of discharge. Mrs. Gonzales will regain swallowing ability from speech therapy by the time of discharge. [Ask the class: What are some expected outcomes for these goals?] The expected outcomes for Mrs. Gonzales' goals are: 1. Mrs. Gonzales' weight at discharge will be within 2 lb. of admission weight. 2. Mrs. Gonzales will not exhibit signs of aspiration before discharge. 3. Mrs. Gonzales' albumin and prealbumin levels will remain normal before discharge. 4. Mrs. Gonzales will progress to an oral diet before discharge to restorative care facility.

Case Study (Cont.)

Matt must keep in mind that Mrs. Gonzales will progress to restorative care and return to oral feedings, and also must consider cultural preferences. Matt knows that food safety is an important issue. Matt consults the dietitian, and together they develop a teaching plan regarding food safety for the foods that Mrs. Gonzales' family will be preparing at home. What expected outcomes would Matt set for the teaching session? What nursing actions are appropriate for evaluating whether goals have been met? Consider the patient's perspective. Check measurable outcomes. Consult with interdisciplinary staff. Matt sees Mrs. Gonzales before discharge to a restorative care facility for rehabilitation before returning home. Mrs. Gonzales now is able to consume all of her required nutrients with a ground diet and nectar-thickened liquids. Matt removes the feeding tube in preparation for her transport to the new facility. Matt advises Mrs. Gonzales to continue the care plan and emphasizes that it is important to continue speech therapy.

Biochemical Measurements

Measurements in the nutritional assessment include: Complete blood count Total lymphocyte count Thyroid level - effects metabolism Comprehensive metabolic panel Liver function tests Urinalysis Serum albumin Cholesterol Hemoglobin Serum transferrin - iron deficiency anemia

Anatomy and Physiology of the Gastrointestinal Tract

Mouth Mechanical and chemical breakdown of food Esophagus Peristalsis moves food to the stomach Stomach Stores swallowed food Mixes food and liquid with digestive juices Empties contents into small intestine Small intestine: approximately 23 feet Duodenum, jejunum, and ileum facilitate digestion and absorption of H20 Large intestine: approximately 5 to 6 feet Primary organ of bowel elimination Rectum and anus Rectum holds fecal contents; anus expels feces through the process of defecation

Case Study (Cont.)

Nutritional management Insert feeding tube as ordered. Initiate enteral feeding as prescribed. Advance tube feeding as tolerated; monitor for tolerance. Aspiration precautions Position Mrs. Gonzales with head of bed elevated a minimum of 30 degrees. Check tube placement every 4 to 6 hours. Check gastric residual volume every 4 hours. Continue with speech therapy.

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Organize the nursing history around factors that affect elimination. Determination of the usual elimination pattern: Include frequency and time of day. Having the patient or caregiver complete a bowel elimination diary provides an accurate assessment of a patient's current bowel elimination pattern. Patient's description of usual stool characteristics: Determine if the stool is normally watery or formed, soft or hard, and the typical color. Ask the patient to describe a normal stool's shape and the number of stools per day. Use a scale such as the Bristol Stool Form Scale to get an objective measure of stool characteristics. Identification of routines followed to promote bowel elimination: Examples are drinking hot liquids, eating specific foods, or taking time to defecate during a certain part of the day. Use of laxatives, enemas, or bulk-forming fiber additives. Presence and status of bowel diversions: If the patient has an ostomy, assess frequency of emptying the patient's ostomy pouch, character of feces, appearance and condition of the stoma (color, height at or above skin level), condition of peristomal skin, type of pouching system device used, and methods used to maintain the function of the ostomy. Changes in appetite: Include changes in eating patterns and a change in weight (amount of loss or gain). If a loss of weight is present, ask if the patient intended to lose weight, as with a diet or exercise routine or if it happened unexpectedly. Diet history: Determine the patient's dietary preferences for a day. Determine the intake of fruits, vegetables, whole grains, and regularity of mealtimes. Description of daily fluid intake: This includes the type and amount of fluid. The patient often estimates the amount using common household measurements. History of surgery or illnesses affecting the GI tract: This information helps explain symptoms, the potential for maintaining or restoring normal bowel elimination pattern, and whether there is a family history of GI cancer. Medication history: Ask the patient for a list of all the medications they take and assess whether there are any such as laxatives, antacids, iron supplements, and analgesics that alter defecation or fecal characteristics. Emotional state: The patient's emotional status may alter frequency of defecation. Ask the patient if they have experienced unusual stress, and if they feel this may have caused a change in bowel movements. History of exercise: Ask the patient to specifically describe the type and amount of daily exercise. History of pain or discomfort: Ask the patient whether there is a history of abdominal or anal pain. The type, frequency, and location of pain help identify the source of the problem. For instance, cramping pain, nausea, and the absence of bowel movements could indicate that there is an intestinal obstruction. Social history: Patients have many different living arrangements. Where patients live affects their toileting habits. If the patient shares living quarters, ask how many bathrooms there are. Find out if the patient has to share a bathroom, creating a need to adjust the time they use the bathroom to accommodate others. If the patient lives alone, can they ambulate safely to the toilet? When patients are not independent in bowel management, determine who assists them and how. Mobility and dexterity: Evaluate patients' mobility and dexterity to determine if they need assistive devices or help from personnel. [Review Box 47-3, Nursing Assessment Questions, with students.] [Shown is Figure 47-6: Bristol stool form scale. (Used with permission. Bristol Stool Form Guideline, http://www.aboutconstipation.org/bristol.)]

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Parenteral nutrition (PN) is the administration of a solution consisting of glucose, amino acids, minerals, electrolytes, trace elements, and vitamins through a peripheral or central venous catheter (CVC). Administration of PN is used when the GI tract cannot be used or cannot absorb nutrients in sufficient amounts to provide adequate nutrition. There is an increased risk for infection when administering PN because it requires intravascular access and because of the high concentration of glucose in PN solutions. A PN solution is formulated to meet a patient's specific nutritional needs and is adjusted as needed based on a patient's laboratory values and metabolic and nutritional status. The health care team evaluates the need for PN on a daily basis. The goal is to move toward the use of the GI tract for oral intake or EN as soon as possible. There are two types of PN: central and peripheral. Parenteral nutrition solutions that contain 10% dextrose or greater are administered via central PN (through the CVCs), as they irritate small peripheral veins. Parenteral nutrition solutions with osmolality less than 900 mOsm may be administered through peripheral veins. Peripheral PN is usually used only for a short period because it is still irritating to the blood vessels.

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Parenteral nutrition therapy requires a CVC inserted into the superior vena cava via the subclavian vein or the jugular vein. The administration of PN can also be given via a peripherally inserted central catheter (PICC). A chest x-ray film confirms the location of the CVC when it is initially placed and when misplacement is suspected. Instead of a catheter, patients have a long-term central venous access device (CVAD) such as a tunneled catheter or an implanted port. When administering PN, be sure the formula ordered is being delivered into a catheter or CVAD that terminates in the appropriate position. Before beginning an infusion, inspect the solution and check the contents carefully to make sure that it is formulated according to the health care provider order. The solution is provided at a specified rate using an infusion pump over the course of the day to meet the patient's nutritional needs. Patients receiving PN at home frequently administer the entire daily solution over 10 or 12 hours at night. Nursing care for the patient receiving PN focuses on seven major nursing goals: (1) preventing infection; (2) maintaining the PN system; (3) preventing metabolic, electrolyte, or fluid balance complications; (4) ensuring that the patient's nutritional and fluid needs are being met; (5) evaluating the continued need for PN or if oral intake or EN may be initiated and, if not; (6) planning for home PN if this is indicated; and (7) supporting the patient and family during major lifestyle changes. Monitor patients receiving PN closely to assess for tolerance, the need for adjustments to the solution, and efficacy of the nutrition provided. Frequent laboratory measurements for metabolic or electrolyte abnormalities and assessment of fluid balance, weight trend, and the ability to heal should occur during administration. Laboratory monitoring includes frequent blood glucose testing because the high dextrose (glucose) content of the solution can easily lead to hyperglycemia and require supplemental insulin as needed. [Review Box 33-11 in the textbook, Procedural Guidelines: Blood Glucose Monitoring.] [Shown is Figure 33-7, Blood glucose monitor. (Courtesy LifeScan, Inc., Milpitas, CA.)]

Nursing Process: Evaluation

Patient care Compare patient data to expected outcomes. Reassess the patient and revise goals as needed. Patient expectations Individualize the nutrition care plan and focus on the patient. Allow the patient to make informed choices.

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Patients discharged from a hospital with diet prescriptions often need dietary education to plan meals that meet specific therapeutic requirements. Restorative care includes immediate postsurgical, posthospitalization, and routine medical care. Integrate preparation for the restorative aspect of patient care within the acute care setting. Medical nutrition therapy (MNT) is the use of specific nutritional therapies to treat an illness, injury, or condition. Medical nutrition therapy is necessary to assist the ability of the body to metabolize certain nutrients, correct nutritional deficiencies related to a disease, and eliminate foods that may exacerbate disease symptoms. Patients with specific diseases often need modified dietary intake patterns to achieve good nutrition. Work with the physician or health care provider and RD when planning and implementing modified diets. Sometimes specialized nutritional therapies such as EN and PN continue beyond the hospital setting to the home setting. In these cases it is important to determine a feeding regimen that best meets a patient's lifestyle. In addition, the regimen must meet the patient's nutritional and fluid needs based on the clinical condition and be compatible with the type of feeding tube. As a home care nurse you provide education for patients or family caregivers so they can administer PN or EN; assess the catheter or feeding tube; assess tolerance and adequacy of the nutritional and fluid regimen by monitoring weight, hydration status, or glucose level; watch for signs of infection; and help with troubleshooting and problem prevention. You also help a patient in transition to oral intake when this is indicated by making suggestions for adjusting the nutritional regimen according to the health care provider order.

Factors Influencing Nutrition

Religious and cultural practices Financial issues Appetite Food experiences Environmental factors Disease and illness Medications - taste bad = salt Age

Nursing Process: Diagnosis

Risk for Aspiration Diarrhea Adult Failure to Thrive Deficient Knowledge (nutrition) Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: More Than Body Requirements Readiness for Enhanced Nutrition Risk for Imbalanced Nutrition: More Than Body Requirements Impaired Swallowing Feeding Self-Care Deficit

Geriatric Considerations

Slower metabolic rate = fewer calories needed Diminished thirst sensation Still need same amount of vitamins and minerals as younger individuals Calcium is important for men and women Fiber and bulk important in the diet = bc decr tone and decr motility

Bowel Diversions

Temporary or permanent artificial opening in the abdominal wall via a stoma Located in the ileum (ileostomy) or colon (colostomy) Location of ostomy determines stool consistency Location and type of colostomy depends on medical diagnosis and patient condition need one bc crohns, colon cancer, inflammitory,

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The expected outcomes Matt can set for Mr. Gonzales' family are: Wash hands, preparation surfaces, utensils. Cook meat, poultry, fish, and eggs at 180 degrees. Wash fresh fruits and vegetables. Refrigerate foods at 40 degrees within 2 hours of cooking. Discard spoiled foods. Use plastic laminate or solid surface cutting boards. Wash dish cloths, towels, and sponges with bleach. Clean inside the refrigerator and microwave regularly with bleach or soap. Matt could also evaluate the family in preparing Mrs. Gonzales' food and preventing foodborne illnesses by making a home visit. Nursing actions to verify achievement of the outcomes are to: 1. Ask Mrs. Gonzales if she is experiencing any gastrointestinal discomfort. 2. Weigh Mrs. Gonzales weekly. 3. Monitor Mrs. Gonzales' laboratory values. 4. Ask the SLP about Mrs. Gonzales' swallowing rehabilitation.

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The focus of health promotion is to educate patients and family caregivers about balanced nutrition and to assist them in obtaining resources to eat high-quality meals. An area of particular importance is education about product claims that are misleading: some "reduced-fat" foods still have significant amounts of fat, some "lite" foods still contain considerable calories, and "low cholesterol" does not always mean low fat. Help patients develop a successful weight loss plan that considers their preferences and resources and includes awareness of portion sizes and knowledge of the energy content of food. Health care professionals not only need to be aware of factors related to food safety but also should provide patient education to reduce risks for foodborne illnesses. [Table 33-3 in the textbook provides information on food safety.] [Box 33-8 in the textbook provides an example of patient teaching for food safety.]

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To manage your patient's elimination problems, you need to understand normal elimination and factors that promote, impede, or cause alterations in elimination such as constipation, diarrhea, and fecal incontinence. [Box 35-1 in the textbook shows factors influencing bowel elimination.] Any alteration in bowel elimination is embarrassing for a patient. Be very sensitive about how you communicate, verbally and nonverbally, and be aware of the patient's need for privacy. Constipation is most often caused by changes in diet, medications, mobility, inflammation, environmental factors (such as unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits. It is not a physiological response to aging, but changes in mobility and co-morbidities make this condition more prevalent in the elderly. Regardless of etiology, intestinal motility slows, causing prolonged exposure of the fecal mass to the intestinal wall. Liquid from the feces continues to be absorbed, leaving stool hard and dry. [Box 35-2 in the textbook lists common causes of constipation.] Fecal impaction results from unrelieved constipation. The patient is unable to expel the hardened feces retained in the rectum. In severe impaction the hardened fecal mass extends up into the sigmoid colon. Diarrhea is an increase in the number of stools and the passage of liquid, unformed stools. Some of the most common causes are infection, inflammation, and food intolerance. Intestinal contents pass too quickly through the small intestine and colon to allow for the usual absorption of fluid and nutrients. Dehydration leading to fluid and electrolyte and acid-base imbalances can result from diarrhea. [Table 35-1 in the textbook provides information on conditions that cause diarrhea.] [Box 35-3 in the textbook lists signs of dehydration.] Fecal incontinence is the inability to control the passage of feces and gas from the anus. It may be a temporary or permanent condition. It may be caused by impairment of anal sphincter function or control. Flatulence (having accumulated gas) is one of the most common GI disorders. It refers to a sensation of bloating and abdominal distention accompanied by excess gas. When intestinal motility is reduced as a result of such things as medications, general anesthetics, abdominal surgery, or immobilization, flatulence may become severe, causing abdominal distention and sharp pain. Hemorrhoids are dilated, engorged veins in the lining of the rectum. Causative factors include increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses such as congestive heart failure or chronic liver disease. A hemorrhoid forms either within the anal canal (internal) or through the opening of the anus (external). Passage of hard stool causes hemorrhoid tissue to stretch and bleed.

Scientific Knowledge Base:Nutrients

Water All cell function depends on a fluid environment Vitamins Essential for metabolism Water-soluble or fat-soluble most from diet fat soluble = ADEK = stored in fatty compartments water soluble = C and B - must ingest Minerals Catalysts for enzymatic reactions Macrominerals; trace elements neuro, healing, developmental probs

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Water is critical because cell function depends on a fluid environment. Water makes up 60% to 70% of total body weight. Infants have the greatest percentage of total body water due to greater surface area, and older people have the least. When deprived of water, a person usually cannot survive for more than a few days. We meet our fluid needs by drinking liquids and eating solid foods high in water content such as fresh fruits and vegetables. Digestion produces fluid during food oxidation. In a healthy individual, fluid intake from all sources equals fluid output through elimination, respiration, and sweating. An ill person has an increased need for fluid (e.g., with fever or gastrointestinal [GI] losses). By contrast, he or she also has a decreased ability to excrete fluid (e.g., with cardiopulmonary or renal disease), which often leads to the need for fluid restriction. Vitamins are organic substances present in small amounts in foods that are essential to normal metabolism. They are chemicals that act as catalysts in biochemical reactions. Certain vitamins are currently of interest in their role as antioxidants. These vitamins neutralize substances called free radicals, which produce oxidative damage to body cells and tissues. Researchers think that oxidative damage increases a person's risk for various cancers. Antioxidant vitamins include beta-carotene and vitamins A, C, and E. The body is unable to synthesize vitamins in the required amounts. Vitamin synthesis depends on dietary intake. Vitamin content is usually highest in fresh foods that have minimal exposure to heat, air, or water prior to their use. Vitamin classifications include either the labels of fat-soluble or water-soluble. The fat-soluble vitamins (A, D, E, and K) are stored in the fatty compartments of the body. With the exception of vitamin D, people acquire vitamins through dietary intake. Hypervitaminosis of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified food, and large intake of fish oils. The water-soluble vitamins are vitamin C and the B complex (which is eight vitamins). Water-soluble vitamins absorb easily from the GI tract. Although they are not stored, toxicity can still occur. Minerals are inorganic elements essential to the body as catalysts in biochemical reactions. They are classified as macrominerals when the daily requirement is 100 mg or more and microminerals or trace elements when less than 100 mg is needed daily. Macrominerals help to balance the pH of the body, and specific amounts are necessary in the blood and cells to promote acid-base balance. Interactions occur among trace minerals.

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When patients are unable to ingest food but are still able to digest and absorb nutrients, the use of enteral tube feeding is supported. Feeding tubes are inserted through the nose (nasogastric or nasointestinal), surgically (gastrostomy or jejunostomy), or endoscopically (percutaneous endoscopic gastrostomy or jejunostomy [PEG or PEJ]). If EN therapy is for less than 4 weeks, total, nasogastric, or nasojejunal feeding tubes may be used. Surgical or endoscopically placed tubes are preferred for long-term feeding (more than 6 weeks) to reduce the discomfort of a nasal tube and provide a more secure, reliable access. Most health care settings use small-bore feeding tubes because they create less discomfort for a patient. For the adult, most of these tubes are 8- to 12-French and 36 to 44 inches (90 to 110 cm) long. A stylet is often used during insertion of a small-bore tube to stiffen it. The stylet is removed when correct positioning of the feeding tube is confirmed. Skill 45-3 describes the procedure for initiating nasogastric, gastrostomy, and jejunostomy enteral feedings. Historically, nurses verified feeding tube placement by injecting air through the tube while auscultating the stomach for a gurgling or bubbling sound or asking the patient to speak. However, evidence-based research repeatedly demonstrates auscultation is ineffective in detecting tubes accidentally placed in the lung. Measurement of the pH of secretions withdrawn from the feeding tube helps to differentiate the location of the tube. [Review Box 45-13, Procedural Guidelines: Obtaining Gastrointestinal Aspirate for pH Measurement, Large-Bore, and Small-Bore Feeding Tubes: Intermittent and Continuous Feeding; Box 45-14, Evidence-Based Practice: Accuracy in Determining Placement of Feeding Tubes; and Table 45-7, Enteral Tube Feeding Complications, with students.] [Shown is Figure 45-8: A, Enteral tubes, small-bore. B, Enteral-only connector (ENFit) designed to fit the specific enteral tube.]

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When patients have delayed gastric emptying or have had gastric resection or other surgery in the upper GI tract such as a pancreatectomy, a jejunostomy tube (J-tube) may be inserted to deliver nutrition. [Skill 33-3 in the textbook describes administering enteral nutrition via nasoenteric, gastrostomy, or jejunostomy tubes.] Feedings delivered via J-tube are usually delivered even more slowly (e.g., over a period of hours overnight) because the jejunum lacks the storage and regulated emptying capacity of the stomach. J-tubes are inserted directly into the small intestine through a percutaneous incision, or they may be inserted through a gastrostomy opening into the small intestine. Gastrojejunostomy tubes are tubes that have access to both the stomach and the small intestine. The gastric port may be used for decompression of accumulated stomach content while feeding is delivered into the jejunal port. You need to know which port is gastric and which port is jejunal. [Shown is Figure 33-6, Endoscopic insertion of jejunostomy tube.] It is important to take measures to prevent and monitor for feeding tube displacement. Application of an external disk helps to prevent migration of a G-tube. Daily cleaning and evaluation of the site helps detect problems. Take measures to prevent displacement of a feeding tube, including taping it to the abdomen or tucking it into clothing for security as indicated or even applying an abdominal binder if necessary. Displacement of a tube can lead to infusion of fluid into the peritoneal space, which can lead to serious complications.

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[Discuss the rationales for these interventions] The rationales for the nursing interventions are: 1. The enteral tube feeding will allow for the safe provision of nutrients while the patient's swallowing is rehabilitated with the assistance of the speech-language pathologist. 2. The tube feeding is initiated at a low rate of infusion and increased slowly to allow for maximum tolerance. 3. Abdominal pain, large volume of gastric residuals, and diarrhea are signs of feeding intolerance and the need for the patient to be evaluated promptly. 4. Head of bed elevation at a minimum of 30 to 40 degrees decreases the risk for aspiration. 5. Improperly positioned tubes increase the risk for aspiration. 6. Gastric residual volume indicates if gastric emptying is delayed. Delayed gastric emptying increases the risk for aspiration. 7. Regularly provided speech therapy will assist the patient in regaining the ability to swallow foods and liquids. 8. Speech therapy includes trials of various consistencies of foods and liquids. Aspiration of food and liquids leads to chest congestion and pneumonia.

Elimination factors

eliminated patterns stool characteristics routines bowel diversions appetite changes diet history dialy fluid intake surgery or illness medications emotional state exercise pain or discomfort social history mobility and dexterity

tube feedings

kangaroo pump cant lay down bc gravity check with xray, bubble, pH check in the beginning of each shift start tube feedings slow, draw back for residuals get concerned at 250cc of residues but draw back back in

ascending colostomy descending illeostomy sigmoid single barreled transverse double barreled

lower = more formed stoll higher = more liquid

bristole

type 1 - hard lump nuts 2 - sausage but lumpy 3 - sausage but cracks 4 - snake, smooth 5 - soft blobs with clear edges 6 - fluffy pieces, mushy 7 - watery no soild