Chapter 24

Diabetic patients: An abnormally low blood glucose level.

Hypoglycemia

Nursing Responsibilities:

Monitor diet type, percentage eaten, and whether the meal was tolerated. ●Determine when to advance the patient's diet.

There are two types of parenteral nutrition:

PPN & TPN

Enteral Feeding Methods: a type of intermittent tube feeding that is frequently used, in which a health-care provider-ordered volume of formula is administered at set intervals throughout the day. To administer a large irrigating syringe (50 mL or greater) is attached to the feeding tube.

Bolus feedings

a type of intermittent tube feeding that is frequently used, in which a health-care provider-ordered volume of formula is administered at set intervals throughout the day.

Bolus feedings

Commonly referred to as binge eating, this eating disorder is accompanied by behavior to get rid of some of the calories that were ingested while bingeing, such as self- or medication-induced vomiting (known as purging), excessive exercise, fasting, or the overuse of laxatives.

Bulimia nervosa

Used for those patients who must lose weight.

Calorie restricted diet

Nutrition that uses the GI tract as a delivery system and that involves tube feedings that usually replace all oral intake but may also be given as a supplement to oral ingestion of nutrients.

Enteral nutrition

Used during the acute phase of intestinal disorders when the presence of fiber may exacerbate intestinal pain, produce diarrhea, or cause an intestinal blockage. This diet is often used before intestinal surgery to minimize fecal volume or after surgery to allow the GI system to transition gradually to a regular diet.

Fiber restricted

People with celiac disease must be on a gluten-free diet. However, other people may have a condition known as "nonceliac gluten sensitivity" and also need to avoid gluten. Still others may have a wheat allergy that requires them to avoid gluten-containing foods. Celiac disease is an autoimmune condition, and wheat allergy causes histamine release. Nonceliac gluten sensitivity is not an autoimmune response but has similar symptoms. Often the diagnosis is made if removing gluten from the diet causes symptoms to subside. Gluten is found in wheat, rice, and maize. It is present in foods like barley, flour, couscous, tabouli, and malt vinegar. Sometimes certain meat products and even some pharmaceuticals may contain gluten.

Gluten free diet

Diabetic patients: An abnormally elevated blood glucose level.

Hyperglycemia

A diet that consists of all the liquids found in a clear liquid diet with the addition of all other opaque liquids and food items that become liquid at room temperature.

full liquid diet

Diets that may be modified by preference include:

gluten-free and vegan.

A long-term feeding tube inserted into the jejunum.

jejunostomy tube, or J-tube.

This diet includes all of the items from the full liquid diet plus the addition of foods such as scrambled eggs and cottage cheese. Many items can be included in this diet by altering their texture through extensive cooking or use of a blender or food processor.

mechanical soft diet

A long-term feeding tube inserted into the stomach through the skin and abdominal wall.

percutaneous endoscopic gastrostomy tube (PEG tube)

Complications can arise with enteral tube feeding, such as:

clogged tubes, aspiration, electrolyte imbalance, hyperglycemia, and severe diarrhea.

SUPPORTING NUTRITIONAL INTAKE:

**assessment **mealtime preparation - odors - environment - toileting - patient comfort and positioning - patient cleanliness **assistance with eating **monitoring intake and output

The nurse has just completed the insertion of a nasogastric (NG) tube. The nurse should verify placement by aspirating for gastric contents and checking the pH of the aspirate. The nurse recognizes that the pH of gastric contents is between

1. 1 and 4.

The nurse teaches a diabetic patient that the goal of diabetes treatment is to maintain an HbA1c less than

1. 7%.

The nurse is caring for a severely underweight patient who has an admitting diagnosis of anorexia nervosa. When assessing this patient, the nurse anticipates (select all that apply)

1. Anemia. 6. Muscle weakness.

The nurse is caring for a diabetic patient who requires blood glucose monitoring before meals and at bedtime. When checking the patient's blood glucose before lunch, the nurse documents the reading as 130 mg/dL. What should the nurse do next?

1. Continue to monitor.

The nurse is caring for a patient who has an admitting diagnosis of bulimia nervosa. When assessing this patient, the nurse anticipates (select all that apply)

1. Evidence of dental decay. 2. Complaints of indigestion. 4. Complaints of a sore throat. 5. Symptoms of gastric reflux.

A patient is admitted to a hospital unit with a diagnosis of anorexia nervosa. When caring for this patient, the nurse recognizes that anorexia nervosa is characterized by (select all that apply)

1. Evidence of emaciation. 3. An excessive leanness or wasting of the body. 5. Obsessive thoughts about body shape and weight. 6. Attempts to reduce one's body weight below normal.

When educating a patient about cooking methods, the nurse recognizes that additional teaching is warranted when the patient states that a way to reduce fat intake is

1. Frying.

When caring for a diabetic patient, the nurse checks the morning lab values. The nurse notes that the patient's blood glucose level is 60 mg/dL. The nurse recognizes this reading as consistent with

1. Hypoglycemia.

A nursing instructor evaluates a student nurse's application of theory regarding continuous tube feedings. The nursing instructor recognizes that further teaching is warranted when the student nurse

1. Instructs the patient to maintain a supine position.

A patient has been prescribed the medication Lithium as a mood-stabilizing agent. When administering Lithium to the patient, the nurse closely monitors

1. Sodium.

A patient has been prescribed a corticosteroid medication. The nurse educates the patient about corticosteroids. The nurse recognizes that teaching has been effective when the patient identifies an example of a side effect from corticosteroid use as

1. Weight gain.

The nurse educates a class of adolescents about eating disorders. The nurse teaches that eating disorders (select all that apply)

2. Are more prevalent in females than in males. 3. Can cause a patient's health to be severely affected. 4. Generally occur during adolescence or early adulthood. 5. Are evidenced by extreme disturbances in eating habits. 6. May result from either physical or psychological causes.

The nurse is caring for a patient who has a nasogastric (NG) tube to suction. When caring for this patient, the nurse should (select all that apply)

2. Irrigate the clogged tube according to facility policy. 5. Assess color, amount, and consistency of gastric drainage. 6. Assess tubing connections to prevent accidental disconnection.

When educating a diabetic patient about complex carbohydrates, the nurse teaches that complex carbohydrates require the body to work harder to break them down to use for energy, helping to maintain a more consistent blood glucose level. The nurse identifies an example of a complex carbohydrate as

2. Legumes.

When educating a diabetic patient about the HbA1c test, the nurse teaches that the HbA1c gives a better overall picture of glycemic control by measuring the amount of glucose present over a period of

3. 2 to 3 months.

When performing an initial admission assessment on a diabetic patient, the nurse checks the patient's blood glucose level. The nurse notes that the patient's blood glucose level is 280 mg/dL. The nurse recognizes this reading as consistent with

3. Hyperglycemia.

When inserting a nasogastric (NG) tube, the patient becomes cyanotic, coughs incessantly, and is unable to speak. The nurse should

3. Immediately remove the tube completely.

A patient has been prescribed isoniazid (INH), a medication to treat tuberculosis. When administering INH to the patient, the nurse also anticipates administering

3. Vitamin B6.

The emergency room nurse admits an adult patient who is admitted for a drug overdose. The physician writes an order for the nurse to instill charcoal through a nasogastric (NG) tube. When selecting the size of the NG tube, the nurse chooses size

4. 16 French.

When providing diabetic teaching to a newly diagnosed diabetic patient, the nurse teaches that the best indicator of long-term glycemic control is obtained through measuring a patient's

4. Glycosylated hemoglobin.

When inserting a nasogastric (NG) tube, the patient gags and coughs continually and does not appear able to stop. The nurse should

4. Use a flashlight and tongue blade to view the posterior pharynx.

An eating disorder marked by relentless self-starvation in an effort to reduce the body weight below normal. This disorder is characterized by an excessive leanness or wasting of the body, known as emaciation.

Anorexia nervosa

Used to manage calorie and carbohydrate intake for patients with diabetes mellitus, primarily those who are insulin dependent.

Diabetic diet

Used for patients who are experiencing problems with fat malabsorption, such as those with disorders affecting the gallbladder, liver, lymphatic system, pancreas, or intestines. It also may be used for those patients who have elevated triglyceride, lipid, or cholesterol levels, as well as for patients who need general weight loss.

Fat restricted diet

A health-care provider may order any type of diet to be provided in several smaller feedings throughout the day rather than the traditional three meals per day. This is used with those patients who have difficulty tolerating larger meals or who simply are unable to eat more than a few bites at a time, as well as those who need to have food gradually reintroduced. Often elderly patients are only able to eat small amounts at a time. This makes it difficult for them to obtain the needed nutrients in the traditional three meals per day. By increasing the number of meal or snack times from three to five or six per day, the patient has a better chance of receiving the needed nutrients.

Five to six small, frequent feedings diet

a reaction by the patient's immune system to an allergen, which is a food protein that, once ingested, causes the immune system to develop antibodies.

Food allergy

An adverse, nonallergic reaction to a food without activation of the immune response.

Food intolerance

an adverse reaction to a food without activation of the immune response.

Food intolerance

When educating a diabetic patient about simple carbohydrates, the nurse teaches that simple carbohydrates are quickly converted to glucose and can be used to quickly raise the blood glucose. The nurse identifies an example of a simple carbohydrate as

Fruit juices

the process of reducing the pressure within the stomach by emptying it of its contents. An NG tube is inserted into the stomach and connected to low intermittent suction to accomplish this.

Gastric decompression

Used to increase calorie and protein intake in those patients with increased need related to wound healing, growth promotion, and increasing or maintaining weight. High-fat foods also may be added to increase calories available for energy use

High calorie, high protein

Dietary effects that reduce medication absorption typically occur through the influence of increased gastric motility, conditions within the GI tract that are either too acidic or too alkaline, or direct interaction of food with a medication.

Important information

Excretion refers to the process of eliminating a medication or its metabolites or nutritional components from the body, a function usually performed by the kidneys. The length of time it takes to excrete a medication influences the extent of the medication's therapeutic effects. Slowed or inadequate excretion can raise the blood level of a medication and cause toxicity as successive scheduled doses are administered. Rapid or increased excretion can limit or greatly reduce the medication's therapeutic effect.

Important information

Metabolism of food and medications occurs through the use of enzyme systems in the small intestine and liver. Some medications can inhibit or induce the activities of these enzyme systems, impairing the metabolism of nutrients. For example, the anticonvulsant phenytoin induces the liver system that metabolizes folate, vitamin D, and vitamin K. Patients taking this anticonvulsant will need additional supplements of these vitamins.

Important information

NG and NI tubes inserted for instillation of nutritional feedings are generally softer and smaller than those used for gastric decompression or lavage.; however, they tend to go down easier because they are smaller and softer.

Important information

The side effects of medication, such as nausea, vomiting, altered taste sensation, anorexia, decreased salivation, and sores or lesions in the mouth or the upper GI tract, can inhibit appetite or make food intake painful. Some medications can be very sedating or cause the patient to feel confused; this in turn will interfere with nutritional intake.

Important information

Certain medications can alter the absorption, metabolism, or excretion of nutrients. Alternatively, some nutrients can alter the absorption, metabolism, or excretion of medications.

Information

Check placement of a feeding tube: If the placement of a tube is not confirmed prior to administering a feeding or medication, there is a risk of instilling the formula or medication directly into the lungs via an NG tube or into the sterile peritoneal cavity via a PEG tube or J-tube.

Information

Checking Residual Gastric Volume: Before you can safely administer a tube feeding, not only must you check tube placement but you also must assess the residual gastric volume, or the amount of formula that still remains in the stomach from the previous feeding. Safety: It is vital that you check the residual volume as well as tube placement before instilling each tube feeding.

Information

Continuous Infusion Feedings: Continuous feedings are best administered via an infusion pump at a constant rate over an 8- to 24-hour period. The continuous infusion method promotes better tolerance of feedings and nutrient absorption. Use of the pump provides greater control of the rate and amount of feeding delivered. This method is used with critically ill patients because of the decrease in hypermetabolic response to stress, the risk for aspiration, and the incidence of diarrhea. Continuous feedings should be interrupted every 4 hours to check placement and residual volume, to administer water for hydration if ordered, and to flush the tube to prevent clogging. Safety: These patients must have the head of the bed raised at least 30 degrees continually to reduce the risk of aspiration.

Information

Food intolerance can stem from the body's lack of digestive enzymes or an inability to utilize these enzymes. The resultant symptoms of intolerance are usually of a GI nature, such as bloating, flatulence, diarrhea, or nausea. Treatment of food intolerances requires identification of the offending agent; this can be accomplished by eliminating various foods from the diet over a period of time.

Information

It is important to carefully measure and record all fluids taken in as intake, whether they are taken in by mouth, are given via IV, or are administered as enteral or parenteral fluids. It is also important to measure and record all bodily fluids that are lost as output, including urine, emesis, liquid stool, blood, gastric contents, and drainage. These measures give valuable information about the patient's fluid balance.

Information

Methods for assisting with meals for patients in the hospital include preparing the environment and preparing the patient, as well as assisting the patient with eating, if needed.

Information

NG tubes are shorter than NI tubes because they go only to the stomach. NI tubes are usually smaller in diameter and more flexible than NG tubes. The double lumen tube, also called a Salem sump, is used strictly for gastric decompression.

Information

Nurses are responsible for monitoring the type of diet, percentage eaten, and whether or not the patient tolerated the meal. They are also responsible for advancing the patient's diet when "Advance as tolerated" is ordered. Diabetic patients have many special needs, and the nurse is responsible for teaching as well as assessing the patient for complications such as hypoglycemia and hyperglycemia.

Information

Other food-drug interactions can create medication toxicity.

Information

PPN solutions contain a lower concentration of dextrose than TPN. When administering any type of parenteral nutrition, the nurse must adhere strictly to sterile technique; contamination can lead to serious infection and septicemia.

Information

Patients requiring long-term feedings have surgical endoscopic placement of a percutaneous feeding tube. Percutaneous means that an incision is made through the skin and abdominal wall, allowing the tube to extend from either the stomach or the jejunum to the external surface of the abdomen.

Information

Patients with difficulties tolerating oral intake may receive enteral feedings. Tube feedings can be NG or NI or via the lower GI tract via a PEG tube or J-tube.

Information

Small-bore feeding tubes now require the use of ENFit tubes, bags with tubing, and syringes. These will only connect to one another and will not connect to IV tubing to prevent misconnection errors.

Information

Some drugs can affect appetite or digestion due to side effects. Some drugs can alter the absorption, metabolism, and excretion of nutrients by affecting GI and liver function. Some drugs affect the kidneys and interfere with the excretion of nutrients.

Information

Some medications can affect nutrient intake by inhibiting appetite, causing GI discomfort, or by causing some other reaction that inhibits food intake by making it unpleasant or painful. Other medications can stimulate appetite, increasing the quantity of food ingested.

Information

Tube feedings can be continuous or intermittent bolus. Continuous feedings should be administered with a feeding pump.

Information

Verification of NG/NI tube placement by radiography is the most accurate method. Aspiration of gastric contents and assessment of the pH are used to verify continued presence of the tube in the proper location of the GI tract.

Information

The physician writes an order to discontinue a nasogastric (NG) tube. When discontinuing the NG tube, the nurse should

Instill 10 to 20 mL of air into the NG tube's main lumen.

The physician writes an order for the nurse to insert a nasogastric (NG) tube for gastric decompression. When inserting the NG tube, the nurse should

Instruct the patient to hyperextend his or her head slightly and then gently insert the tube into the intended naris

The nurse is caring for a patient who is receiving formula through intermittent tube feedings. When caring for this patient, the nurse should

Maintain the formula at room temperature

____status means nothing by mouth and is usually ordered for a limited time as preparation for procedures or tests.

NPO

ENTERAL TUBES: Shorter •Inserted through nose and into stomach •Single lumen versus double lumen

Nasogastric tube

ENTERAL TUBES: •Longer •Inserted through nose, through stomach, into duodenum •Smaller in bore size •More flexible

Nasointestinal tube

Diets that are modified by consistency include:

clear liquid, full liquid, mechanical soft, and pureed.

The following are the most common food allergies:

Peanuts Wheat Dairy products Eggs

Used to manage protein intake for those patients with liver or kidney disease.

Protein restricted diet

_____diets are ordered for patients without special nutritional needs.

Regular

Used to manage or limit fluids and electrolytes for patients with renal insufficiency or disease. The renal diet is complex, and the patient's nutritional needs change over the course of the disease. A dietitian specializing in renal disorders may guide the nutritional therapy.

Renal diet

Used for those patients with hypertension, congestive heart failure, or kidney or liver failure, as well as those who require help to prevent or correct fluid retention. The degree of restriction is commensurate with disease severity, severity of symptoms, and the medication regimen prescribed. Typically sodium restrictions range from 2,000 to 3,000 mg per day. While many patients think that simply not adding salt to foods provides adequate sodium restriction, this is not actually the case. Most of the sodium that people ingest comes from processed foods, making it necessary to read labels for sodium content if the patient is sent home on this diet.

Sodium restricted diet

People may choose to be vegan for a number of reasons. Some feel it is better for the environment, some feel that animals should not be food sources for people, and others may decide it is a healthier choice for them personally. Some studies have shown that eating a vegan diet has improved or reversed some diseases, particularly cardiovascular diseases. Those on a vegan diet eat plant-based only. They avoid all meat, including fish and poultry, and any other animal products or by-products. They do not consume eggs, dairy products, or honey. This diet is rich in fruits and vegetables, leafy greens, whole grains, nuts, seeds, legumes, and tofu (soy).

Vegan diet

Common eating disorders include:

anorexia nervosa, bulimia nervosa, and binge eating disorder.

A third type of eating disorder is characterized by episodes of eating large quantities of food at one time, with a loss of control while eating. The person with disorder may eat very quickly and be to a point of discomfort but continue to eat. This disorder is the most common eating disorder in the United States.

binge eating

A type of diet ordered to provide hydration and calories in the form of simple carbohydrates that help meet some of the body's energy needs; most often used postoperatively or during recovery from gastrointestinal disease such as vomiting and diarrhea, when the gut must be introduced slowly to food. Examples of clear liquids include water, broth, and tea without milk.

clear liquid diet

Some common diets modified for disease are:

diabetic, sodium-restricted, fat-restricted, and renal diets.

Nursing Responsibilities for a Patient with a P E G or J-tube:

●Assess tube placement. ●Maintain patency. ●Perform assessment of skin integrity. ●Daily cleansing of tube. ●Assess for gastric residual. ●Elevate head of bed. ●Monitor intake and output. ●Monitor weight. Monitoring for diarrhea or constipation that might result from certain feeding formulas

Monitoring Nutritional Status:

●Daily weights ●Certain laboratory results ●Electrolyte levels ●Prealbumin, albumin, and total protein ●Glucose

Complications Associated with Tube Feedings:

●Nausea and diarrhea ●Clogged tubes ●Aspiration ●Metabolic problems ●Contamination of formula

A type of feeding administered directly into the bloodstream via a central venous catheter, bypassing the GI tract; it provides complete nutrition, including amino acids, dextrose, emulsified fats, vitamins, minerals, and trace elements. It is used for patients with one or more problems that are complicated by malnutrition and low protein levels.

●Partial parenteral nutrition (P P N)

Insertion of an N G Tube for Gastric Decompression:

●Prepare patient ●Prepare supplies for use ●Insert N G tube ●Attach N G tube to suction ●Maintain patency of N G tube

A type of feeding administered through a central venous catheter (CVC) placed in a larger central vein.

●Total parenteral nutrition (T P N)