RHCH 40 Enteral
Priority Decision. The nurse is caring for a patient receiving 1000mL of parenteral nutrition solution over 24 hours. When it is time to change solution, 150mL remain in the bottle. What is the most appropriate action by the nurse? A. Hang the new solution and discard the unused solution. B. Open the IV line and rapidly infuse the remaining solution C. Notify the health care provider for instructions regarding the infusion rate. D. Wait to change the solution until the remaining solution infuses at the prescribed rate.
A. Hang the new solution and discard the unused solution.
Indicate whether the following characteristics of parenteral nutrition apply more to central parenteral nutrition (CPN) or peripheral parenteral nutrition (PPN) A. Limited to 20% glucose B. Tonicity of 1600 mOsm/L C. Nutrients can be infused using smaller volumes D. Supplements oral feedings E. Long-term nutritional support F. Phlebitis more common G. May use peripherally inserted central catheter (CPN)
A. PPN B. CPN C. CPN D. PPN E. CPN F. PPN G. CPN
The nurse is caring for a 47-year-old female patient who is comatose and is receiving continuous enteral nutrition through a soft nasogastric tube. The nurse notes the presence of new crackles in the patient's lungs. In which order will the nurse take action? (Put a comma and a space between each answer choice [A, B, C, D].) a. Check the patient's oxygen saturation. b. Notify the patient's health care provider. c. Measure the tube feeding residual volume. d. Stop administering the continuous feeding.
ANS: D, A, C, B The assessment data indicate that aspiration may have occurred, and the nurse's first action should be to turn off the tube feeding to avoid further aspiration. The next action should be to check the oxygen saturation because this may indicate the need for immediate respiratory suctioning or oxygen administration. The residual volume should be obtained because it provides data about possible causes of aspiration. Finally, the health care provider should be notified and informed of all the assessment data the nurse has just obtained.
Which of these nursing actions included in the plan of care for a patient who is receiving intermittent tube feedings through a percutaneous endoscopic gastrostomy (PEG) tube may be delegated to an LPN/LVN? a. Providing skin care to the area around the tube site b. Assessing the patient's nutritional status at least weekly c. Determining the need for the addition of water to the feedings d. Teaching the patient and family how to administer tube feedings
ANS: A LPN/LVN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require RN-level education and scope of practice.
A 48-year-old man who has just been started on tube feedings of full-strength formula at 100 mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the tube feeding. b. Check gastric residual volumes more frequently. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube.
ANS: A Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea.
A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Shut the feeding off 30 to 60 minutes before the scan. b. Ask the health care provider to reschedule the CT scan. c. Connect the feeding tube to continuous suction during the scan. d. Send the patient to CT scan with oral suction in case of aspiration.
ANS: A The tube feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable.
A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action is best for the nurse to take? a. Ask the health care provider to clarify the written PN order. b. Add a new container of PN using the current tubing and filter. c. Hang a new container of PN and change the IV tubing and filter. d. Infuse the remaining 50 mL and then hang a new container of PN.
ANS: B All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the additional 50 mL will increase patient risk for infection. Changing the IV tubing and filter more frequently than required will unnecessarily increase costs. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes.
After change-of-shift report, which patient will the nurse assess first? a. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left b. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles c. A 30-year-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition d. A 30-year-old woman whose gastrostomy tube is plugged after crushed medications were administered.
ANS: B The patient data suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients should also be assessed as quickly as possible, but the data about them do not suggest any immediately life-threatening complications.
When caring for a 63-year-old woman with a soft, silicone nasogastric tube in place for enteral feedings, the nurse will a. avoid giving medications through the feeding tube. b. flush the tubing after checking for residual volumes. c. administer continuous feedings using an infusion pump. d. replace the tube every 3 days to avoid mucosal damage.
ANS: B The soft silicone feeding tubes are small in diameter and can easily become clogged unless they are flushed after the nurse checks the residual volume. Either intermittent or continuous feedings can be given. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes, but flushing after medication administration is important to avoid clogging.
After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL.
ANS: C Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient's nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient.
A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. The most appropriate action by the nurse is to a. obtain a venous blood glucose specimen. b. slow the infusion rate of the PN infusion. c. recheck the capillary blood glucose in 4 to 6 hours. d. notify the health care provider of the glucose level.
ANS: C Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, notification of the health care provider is not necessary. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse's scope of practice and will decrease the patient's nutritional intake.
A patient is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned on the left side. b. Obtain a daily x-ray to verify tube placement. c. Check the gastric residual volume every 4 to 6 hours. d. Avoid giving bolus tube feedings through the PEG tube.
ANS: C The gastric residual volume is assessed every 4 to 6 hours to decrease the risk for aspiration. The patient does not need to be positioned on the left side. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed. Bolus feedings can be administered through a PEG tube.
A patient's peripheral parenteral nutrition (PN) bag is nearly empty and a new PN bag has not arrived yet from the pharmacy. Which intervention is the priority? a. Monitor the patient's capillary blood glucose until a new PN bag is hung. b. Flush the peripheral line with saline and wait until the new PN bag is available. c. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy. d. Decrease the rate of the current PN infusion to 10 mL/hr until the new bag arrives.
ANS: C To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the nurse's scope of practice. Flushing the line and then waiting for the next bag may lead to hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not the priority.
The nurse receives change-of-shift report about the following four patients. Which patient will the nurse assess first? a. A patient who has malnutrition associated with 4+ generalized pitting edema b. A patient whose parenteral nutrition has 10 mL of solution left in the infusion bag c. A patient whose gastrostomy tube is plugged after crushed medications were given through the tube d. A patient who is receiving continuous enteral feedings and has new-onset crackles throughout the lungs
ANS: D The patient data suggest aspiration has occurred and rapid assessment and intervention are needed. The other patients also should be assessed as quickly as possible, but the data about them do not suggest any immediately life-threatening complications.
What is an indication for parenteral nutrition that is not appropriate indication for enteral tube feedings? A. Head and neck cancer B. Hypermetabolic states C. Malabsorption syndrome D. Protein-calorie malnutrition
C. Malabsorption syndrome
what are contraindications to enteral nutrition?
GI obstruction, prolonged ileus, severe diarrhea or vomiting, and enterocutaneous fistula
what happens in an enteral feeding misconnection?
nutritional formula intended for administration into the GI tract is administered via the wrong route, resulting in serious and potentially life-threatening patient complications (p 901 TABLE 40-12)
what are indications for enteral nutrition?
persons with anorexia, orofacial fractures, head and neck cancer, neurologic or psychiatric conditions that prevent oral intake, extensive burns, or critical illness (especially if mechanical ventilation is required), and those who are receiving chemotherapy or radiation therapy
how often do we check gastric residual volume in gastrically fed pts?
q4hr during first 48 hours; after the enteral feeding goal rate is achieved, gastric residual monitoring may be decreased to every 6 to 8 hours in non-critically ill patients or continued every 4 hours in critically ill patients
when can enteral tube feeds be started after a surgically placed gastrostomy or jejunostomy tube?
within 24-48 hours; don't have to wait for flatus or BM
