MS 47--Enteral feedings/Total parenteral nutrition (TPN)/Abdominal Paracentesis/Bariatric surgeries/NG decompression/Ostomies

What are abnormal ascites (that cause the need for parancentesis) in the first place?

-buildup of protein rich fluid in the abdominal cavity -most often caused by cirrhosis of the liver. -causes increased abdominal girth and distention -respiratory distress is the determining factor in the use of paracentesis to treat ascites, and in the evaluation of treatment effectiveness

when do you need a colostomy ostomy?

when a portion of the bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, trauma)

What do you do when there's fluid imbalances from TPN?

-Listen to the lungs for crackles and respiratory distress -Monitor daily weight and I&O -Use a controlled infusion pump to administer TPN at the prescribed rate -Do not speed up the infusion to catch up (gradual)

Bariatric surgeries

-treatment for morbid obesity when other weight control methods have failed

What could go wrong in enteral feedings?

Overfeeding (infusing more than can be readily digested, resulting in abdominal distention, nausea, and vomiting)

Nasogastric decompression pre procedure nursing actions

gather necessary equipment & supplies

malabsorption surgeries (Roux-en-Y gastric bypass (RNYGB) or simply gastric bypass)

interferes with the absorption of food and nutrients from the GI tract.

What should you do if there's an infection from TPN?

-Check site for local infection (erythema, tenderness, exudate) -Change the dressing on a central line per protocol (48 - 72 hrs) -Change IV tubing per protocol (typically 24 hr) -Watch for signs of an systemic infection (fever, increased WBC, chills, malaise) **DO NOT USE TPN line for other IV bolus fluids and medications***

TPN complication metabolic complication nursing actions

-Do daily lab tests before new solution is prepared -Replace fluids w/a separate IV bolus to prevent volume excess -Monitor for hyperglycemia

Nurses who use GI therapeutic procedures should know how to do the following 6 things:

-Enteral feedings -Total parenteral nutrition (TPN) -Abdominal Paracentesis -NG decompression -Bariatric surgeries -Ostomies

What could go wrong in paracentesis?

-Hypovolemia -Bladder perforation -Peritonitis (Inflammation of the membrane on the abdominal wall and covering the abdominal organs)

How do you get fluid imbalance from TPN?

-It happens because TPN is 3-6 times the osmolarity of blood, which poses a risk for fluid shifts, placing client at increased risk of fluid volume excess -older adult clients are more vulnerable to fluid and electrolyte imbalances

What should you do if there's an air embolism from TPN?

-Look for the signs (sudden onset of dyspnea, chest pain, anxiety, hypoxia) -Close/clamp the catheter immediately and place client on his left side in trendelenburg position to trap air, and administer oxygen -notify provider so air can be aspirated

PRE-procedure for Paracentesis?

-Make sure they're ready for the procedure -Assess their baseline lab results for serum albumin, protein, glucose, amylase, BUN, and creatinine -Make sure they signed the consent form -Gather equipment -Have them pee, or insert an indwelling catheter -Sit them upright, either on edge of bed w/feet supported or a high fowler's position in the bed -Review baseline vital signs, weight, and abdominal girth -Give sedation meds -Give IV bolus fluids or albumin before or after a Paracentesis to restore fluid balance

Paracentesis

-Putting a needle/trocar through the abdominal wall into the peritoneal cavity to relieve abdominal ascites pressure. -Can be performed in a doctor's office , outpatient center, radiology dept., or acute care setting at the bedside -usually performed w/ultrasound as a safety precaution -After it's drained, ascetic fluid can be sent for lab culture

Client education for bladder performation during paracentesis?

-Tell us if you get signs of a bladder perforation

What do you do if the pt gets a bladder perforation during paracentesis?

-The nurse should tell the provider immediately

Nasogastric decompression post procedure nursing actions

-assess & maintain proper function of the NG tube & suction equipment -maintain accurate I&O -assess bowel sounds & abdominal girth; return of flatus -encourage repositioning and ambulation increase peristalsis -monitor tube for displacement (decrease in drainage, increased n/v, distention) -assess pertinent lab results (electroytes, hematocrit) -provide frequent oral & nares care

Ostomies post procedure nursing actions

-assess type & fit of the ostomy appliance. monitor for leakage (risk to skin integrity). Fit ostomy appliance based on: type of ostomy, location of ostomy, how well the client can see and manually use it -assess peristomal skin integrity & appearance of stoma. should appear pink and moist -apply skin barriers & creams (adhesive paste) to peristomal skin & allow to dry before applying a new appliance -evaluate stoma output, b/c it should be more liquid and acidic the closer it is to the small intestine -empty bag when its 1/4 - 1/2 full of drainage -assess for fluid & electrolyte imbalances, particularly w/ a new ileostomy -evaluate ability of the client or support person to perform ostomy care

Paracentesis considerations post procedure client education

-avoid alcohol, maintain a low sodium diet, take prescribed meds, monitor puncture site for bleeding or leakage of fluid -report changes in mental and cognitive status due to change in fluid and electrolyte balance -change positions slowly to decrease the risk of falls, which can be related to hypovolemia from the removal of ascites fluid

malabsorption/malnutrition

-because bariatric surgeries reduce the size of the stomach or bypass portions of the intestinal tract, fewer nutrients are ingested and absorbed

When do you know it's time for enteral feedings?

-can't eat b/c of a med condition (comatose, intubated) -sicknesses that cause difficulty swallowing or increase risk of aspiration (stroke, parkinson's, MS) -inability to maintain adequate oral nutritional intake and need for supplementation due to increased metabolic demands (cancer therapy, burns, sepsis)

TPN interventions

-check capillary glucose every 4 - 6 hr for at least the first 24 hrs -clients receiving TPN frequently need supplemental regular insulin until the pancreas can increase its endogenous production of insulin -keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available -if a bag is unavailable and administered late, do not attempt to catch up by increasing the infusion rate because the client can develop hyperglycemia -OLDER ADULT CLIENTS have an increased incidence of glucose intolerance

What do you do when there's overfeeding

-check residual every 4 to 6 hrs -follow protocol for slowing/withholding feedings for excess residual volumes (100-200 ml, restart at lower rate after rest period) -check pump for proper operation and ensure feeing infused at correct rate

What actual sicknessess do pts usually have that tells you it's time for TPN

-chronic pancreatitis -diffuse peritonitis -short bowel syndrome -gastric paresis from diabetes mellitus -severe burns

How do you prepare the pt for a TPN?

-determine client's readiness for TPN -obtain daily lab values, including electrolytes

Ostomies pre procedure nursing actions

-determine client's readiness for the procedure (assess visual acuity, manual dexterity, cognitive status, cultural influences, support system) -initiate a referral to the wound stony care nurse (WOCN) for ostomy placement marking & client teaching -work collaboratively w/WOCN to being teaching the client and support person about ostomy care & management

ostomies post procedure client education

-educate client regarding dietary changes & ostomy appliances that can help manage flatus and odor --foods that can cause odor: fish, eggs, asparagus, garlic, beans, dark green leafy vegetables. buttermilk, cranberry juice, parsley & yogurt help decrease odor --foods that cause gas include dark green leafy vegetables, beer, carbonated beverages, dairy products, corn. Chewing gum, skipping meals, smoking also cause gas. Yogurt, crackers, toast can be ingested to decrease gas --after an ostomy involving small intestine is placed, instruct client to avoid high-fiber foods for the 1st 2 months after surgery, chew food well, increase fluid intake, & evaluate for evidence of blockage when slowly adding high-fiber food to diet --proper appliance fit and maintenance prevent odor when pouch is not open. filters, deodorizers, or a breath mint can be placed in the pouch to minimize odor while the pouch is open --provide opportunities for the client to discuss feelings about ostomy & concerns about its effect on client's life. encourage client to look at and touch stoma --refer client to a local ostomy support group

What do you need to do before the bariatric surgery (preprocedure)?

-encourage client to express emotions about eating behaviors, weight, and weight loss to identify psychosocial factors- obesity -ensure client understands needed diet and lifestyle changes -prepare client for postoperative course and potential complications -arrange for availability of a bariatric bed/mechanical lifting devices to prevent client/staff injury -look at their baseline lab results (CBC, electrolytes, BUN, creatinine, HbA1C, iron, Vit B12, thiamine, and folate) -apply sequential compression stockings to help prevent deep vein thrombosis

Paracentesis PRE-procedure client education

-explain procedure and its purpose -local anesthetics will be used at the insertion site -there can be pressure or pain w/needle insertion -assess the client's knowledge of the procedure

Ongoing care for TPN once it's already been started and everything

-flow rate is gradually increased and gradually decreased to allow body adjustment ***NEVER abruptly stop TPN, an abrupt rate change can alter blood glucose levels significantly***** -assess vital signs every 4-8 hrs -follow sterile procedures to minimize the risk of sepsis - TPN solution is prepared by pharmacy aseptic technique w/laminer flow hood - Change tubing and solution bag (even if not empty) every 24 hrs - filter is added to tubing to collect particles from the solution - do not use the line for other IV bolus solutions - do not add anything to the solution due to risks of contamination and incompatibility - use sterile procedures, including a mask, when changing the central line dressing

main types of ostomie performed in the abdominal area

-ileostomy: surgical opening into the ileum to drain stool, which is typically frequent and liquid since large intestine is bypassed -colostomy: opening into large intestine to drain stool, w/the ascending colon producing more liquid stools, the transverse colon producing more formed stools, and the sigmoid colon producing near-normal stool

Bariatric surgeries considerations post procedure client education

-instruct client on limitations regarding liquids or pureed foods for the 1st 6 weeks, as well as the volume that can be consumed (often not to exceed 1 cup) -instruct client to walk daily for at least 30 min -remind client that overeating can dilate the surgically created pouch causing weight to be regained -instruct client to take vitamin & mineral supplements

malabsorption/malnutrition client eduction

-instruct client to eat two servings of protein a day -instruct client to eat only nutrition-dense foods ***avoid empty calories i.e. colas/fruit drinks

Refeeding syndrome nursing actions

-look for any new onset of confusion or seizures -assess for shallow respirators -monitor for increased muscular weakness -notify the provider and obtain serum electrolytes if needed

What should you do AFTER the paracentesis procedure (postprocedure)

-maintain pressure at the insertion site for several mins. -apply dressing to the site -if the insertion site continues to leak after holding pressure for several mins, dry sterile gauze dressings should be applied and changed often -check vital signs, record weight, measure abdominal girth, document and compare to preprocedure measurements -continue to monitor vital signs and insertion site per facility protocol -monitor temperature every 4 hr for a minimum of 48 hr (fever can indicate bowel perforation) -assess I&O every 4 hr -administer meds (diuretics {spironolactone/furosemide} to control fluid volume) -potassium supplement can be necessary when a loop diuretic (furosemide) has been administered -administer IV bolus fluids or albumin as prescribed -assist the client into a position of comfort w/ head of bed elevated to promote lung expansion -document color, odor, consistency, amount of fluid removed, location of insertion site, evidence of leakage, manifestations of hypovolemia, changes in mental status -continue to monitoring serum albumin, protein, glucose, amylase, electrolytes, BUN, creatinine levels

Enteral feedings indications client presentation

-malnutrition (decreased prealbumin, decreased transferrin or total iron-binding capacity) -aspiration pneumonia

intestinal obstruction nursing actions

-monitor & record output from the stoma -assess for manifestations of obstruction, including abdominal pain, hypoactive or absent bowel sounds, distention, n/v, notify surgeon of unexpected findings

malabsorption/malnutrition nursing actions

-monitor client's tolerance of increasing amounts of food/fluids -refer client for dietary management -encourage client to consume meals in a low-fowler's position and to remain in this position for 30 mins after eating to delay stomach emptying and minimize dumping syndrome

nasogastric decompression complicaitons fluid/electrolyte imbalance nursing actions

-monitor for fluid/electrolyte imbalance (metabolic acidosis: low obstruction; alkalosis: high obstruction) -Monitor I&O, observing for discrepancies

Bariatric surgeries considerations post procedure nursing actions

-monitor for leak of anastomosis (increasing back, shoulder, abdominal pain; restlessness; tachycardia; oliguria) -notify provider for suspected nasogastric tube displacement -provide postoperative care and prevent post op complications -monitor for development of postoperative complications that are at increased risk due to obesity (atelectasis, thromboembolism, skin fold breakdown, incisional hernia, peritonitis) -assess the airway and oxygen saturation per facility protocol. maintain client in semi-fowler's position for lung expansion -monitor bowel sounds -apply an abdominal binder to prevent dehiscence -ambulate client as soon as possible -resume fluids (1st fluids can be restricted to 30 ml and increased in frequency and volume) -provide 6 small meals a day when client can resume oral nutrients. Observe for indication of dumping syndrome (cramps, diarrhea, tachycardia, dizziness, fatigue) -collaborate w/case manager & mental health resources to assist with long-term behavior modification

What should you do DURING a parencentesis procedure (intraprocedure)?

-monitor vital signs -adhere to standard precautions -drain 4-6 L fluid is slowly from abdomen by gravity. -label lab specimens and send to lab

What should you do if the pt has diarrhea from enteral feedings?

-slow rate of feeding & notify provider -confer w/dietitian -provide skin care and protection -evaluate for Clostridium difficile of diarrhea continues, esp if it has a very foul odor

What do you do when a patient gets hypovolemia during a Paracentesis?

-slow the drainage of fluid down, and give plasma expanders like albumin, to help get-albumin higher -monitor for evidence of hypovolemia, such as tachycardia, hypotension, pallor, diaphoresis, dizziness -report unexpected findings to the provider

Complication aspiration pneumonia nursing actions

-stop the feeding -turn client on side and suction airway give O2 -monitor vital signs for an elevated temperature -auscultate breath sounds for increased congestion and diminishing breath sounds -notify the provider and obtain a chest x-ray

What does the nurse do if you get peritonitis during paracentesis?

-tell provider immediately

Client education for Peritonitis

-tell us if you get any signs of peritonitis

What happens when you get peritonitis from a paracentesis?

-the needle was inserted wrong causing an injury -manifestations include sharp, constant abdominal pain, fever, n/v, diminished or absent bowel sounds

Nasogastric decompression indications client presentation

-vomiting (begins w/stomach contents & continues until fecal material is also being regurgitated) -bowel sounds absent (paralytic ileus) or hyperactive & high pitched (obstruction) -intermittent, colicky abdominal pain & distention -hiccups -abdominal distention

Dehydration

-warn client that excessive thirst or concentrated urine can be an indication of dehydration and th surgeon should be notified -work with the client to est. goals and schedule for adequate daily fluid intake

Manifestations for needing TPN

-weight loss greater than 10% of body weight and NPO or unable to eat or drink for more than 5 days -hypermetabolic state -muscle wasting, poor tissue healing, burns, bowel disease disorders, acute kidney failure

Vertical-Banded gastroplasty

-where you staple a portion of the stomach to decrease its functional size

1. A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? a. client report of upper chest pain b. decreased urine output c. pallor d. temperature elevation 2. A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply) a. obtain a capillary blood glucose four times daily. b. administer prescribed medications through a secondary port on the TPN IV tubing. c. Monitor vital signs three times during the 12-hr shift d. change the TPN IV tubing every 24 hr. e. Ensure a daily aPTT is obtained 3.A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? a. place a clean towel near the drainage site. b. apply a dry, sterile dressing c. apply direct pressure to the site d. place the client in a supine positon 4.A nurse is completing discharge teaching with a client who is 3 days postoperative following a transverse colostomy. Which of the following should the nurse include in the teaching? a. mucus will be present in stool for 5 to 7 days after surgery. b. expect 500 to 1,000 mL of semi liquid stool after 2 weeks c. stoma should be moist and pink d. change the ostomy bag when it is 3/4 full 5.A nurse is caring for a client who is receiving TPN solution. The current bag of solution was hung 24 hr ago, and 400 ml remains to infuse. Which of the following is the appropriate action for the nurse to take? a. remove the current bag and hang a new bag b. infuse the remaining solution at the current rate and then hang a new bag c. increase the infusion rate so the remaining solution is administered within the hour and hang a new bag d. remove the current bag and hang a bag of lactated ringers

1: D 2: A,C,D 3: B 4: C 5: A

Bariatric surgeries indications client presentation

BMI greater than 40, or BMI greater than 35 w/comorbidities

What could go wrong taking TPN?

Hyperglycemia (metabolic issue) Hypoglycemia (metabolic issue) Vitamin deficiencies Air embolism Infection Fluid Imbalance

What medicines can I take to lose weight?

Orlistat - prevents digestion of fats --Adverse effects are oily discharge, reduced food/vitamin absorption, decreased bile flow Lorcaserin - stimulates serotonin receptors in the hypothalamus to curb appetite. --Adverse effects: headache/dry mouth/fatigue/nausea Phentermine-Topiramate - suppresses the appetite and induces a feeling of satiety. --Adverse effects include dry mouth, constipation, nausea, change in taste, dizziness, insomnia, and numbness and tingling of extremities --Don't give it if client has hyperthyroidism, glaucoma, or is taking an MAOI

Bariatric surgeries gastric/malabsorption

Restrictive surgeries Vertical-banded gastroplasty Malabsorption surgeries

What are the signs that you need total parenteral nutrition

any condition that : -affects the ability to absorb nutrition -has prolonged recovery -creates a hyper metabolic state -creates a chronic malnutrition

What disorders cause the need for nasogastric decompression?

any disorder that causes an intestinal obstruction (surgery, trauma, GI tract infections, conditions where peristalsis is absent, etc)

Enteral feedings

are instituted when a client is unable to take adequate nutrition orally

nasogastric decompression complications skin breakdown nursing actions

assess nasal skin for irritation

How do you get hypovolemia during Paracentesis?

because when the fluid's removed, it can also remove alot of protein, causing albumin levels to get dangerously low, and a shift in intravascular volume

intestinal obstruction

can occur for a variety of reasons

Complications Aspiration pneumonia

can occur secondary to aspiration of feeding, can be a life-threatening complication. Tube displacement is the primary cause of aspiration of feeding

How can you get an infection doing TPN?

concentrated glucose can become a medium for bacteria

Bariatric surgeries complications

dehydration malabsorption/malnutrition

Nasogastric decompression complications

fluid/electrolyte imbalance skin breakdown

Bariatric surgeries indications diagnosis

history of morbid obesity w/unsuccessful attempts at nonsurgical weight loss

TPN Metabolic Complications:

hyperglycemia, hypoglycemia, and vitamin deficiencies

When do you know you need to give a pt the paracentesis?

if the pt has a hard time expanding their lungs, have increased abdominal girth, or rapid weight gain

How can an air embolism cause problems in TPN?

if there's an air pressure change during tubing changes

Nasogastric decompression pre procedure client education

instruct client on the purpose of NG tube and client's role in its placement

Nasogastric decompression post procedure client education

instruct client to maintain NPO status

ostomies pre procedure client education

instruct the client & support person regarding care and management of an ostomy

Total Parenteral Nutrition

is a hypertonic IV bolus solution. The purpose is to prevent or correct nutritional deficiencies and minimize adverse effects of malnourishment -administered usually through a central line (triple lumen, single or double lumen or PICC line) -contains complete nutrition, including calories in a high concentration of dextrose(10% to 50%), lipids, fatty acids, protein, electrolytes, vitamins, and trace elements. Standard IV bolus therapy typically no more than 700 calories/day -partial parenteral nutrition or peripheral parenteral nutrition (PPN) = less hypertonic intended for short-term use, given in the large peripheral vein. usual dextrose concentration is 10% or less. Make sure they don't get phlebitis from doing this

Complications Refeeding syndrome

is a potentially life-threatening condition that occurs when enteral feeding is started in a client who is in a starvation state and whose body has begun to catabolize protein and fat for energy

Ostomies

is a surgical opening from the inside of the body to the outside and can be located in various areas of the body. can be permanent or temporary. -stoma is the artificial opening created during the stony surgery

What does Restrictive surgeries (laparoscopic adjustable gastric band (LAGB) or laparoscopic sleeve gastrectomy (LSG)) do?

it limits the amount of food eaten at one time due to decreased volume capacity

What are the signs of bladder perforation during Paracentesis?

it's rare but possible. Manifestations include hematuria, low or no urine output, suprapubic pain or distention, systems of cystitis and fever

intestinal obstruction client education

note indications of an intestinal obstruction following discharge

stomal ischemia/necrosis nursing actions

obtain vial signs, oxygen sat, current lab results. notify provider or surgeon of unexpected findings

Enteral administration is food or drug administration via the human gastrointestinal tract. It involves the esophagus, stomach, and small and large intestines. This contrasts with parenteral nutrition or drug administration, which

occurs from routes outside the GI tract, such as intravenous routes.

What else could go wrong with enteral feedings? Diahrrea

occurs secondary to concentration of feeding or its constituents

stomal ischemia/necrosis

stomal appearance should normally be pink or red & moist --signs of stomal ischemia are pale pink or bluish purple color & dry appearance --if the stoma appears black or purple in color, this indicates a serious impairment of blood flow & requires immediate intervention

ostomies complications

stomal ischemia/necrosis intestinal obstruction

stomal ischemia/necrosis client education

teach client to watch for indications of stomal ischemia/necrosis

How are these procedures actuallly therapeutic (how do they help you)?

they help you eat (nutrition), treat any obstructions, obesity or other disorders

when do you need an ileostomy ostomy?

when the entire colon must be removed due to disease (Crohn's disease, ulcerative colitis)

When do you need to have Nasogastric decompression?

when there's an intestinal obstruction