Nutrition Chapter 14: Nutrient Delivery

Gastrointestinal

- Cramping, distention, bloating, gas pains, nausea, vomiting, diarrhea* - Initiate and increase amount of formula gradually. - Bring formula to room temperature before feeding. - Change to a lactose-free formula. - Decrease fat content of formula. - Administer drug therapy as ordered (e.g., Lactinex, kaolin-pectin, Lomotil) - Change to a formula with a lower osmolality - Change to a formula with a different fiber content, including soluble fiber and excluding insoluble fiber - Practice good personal hygiene when handling any feeding product - Evaluate diarrhea-causing medications the client may be receiving (e.g., antibiotics, digitalis)

Diet Manuals

- Current accreditation standards (both long-term and acute care) require all health-care institutions to have a diet manual available to all team members - Electronic manuals are often used and may be available on an organization's computer system - The diet manual defines and describes all diets used as part of nutritional therapy for clients

One thousand milliliters of a D5W solution provides ____ grams of CHO and ____ kcal. A. 50; 170 B. 5; 20 C. 50; 200 D. 5; 17

A. 50; 170

Careful administration of central parenteral nutrition includes all of the following except: A. A standardized process for ordering and administration B. Close monitoring C. Abrupt withdrawal D. A strict schedule

C. Abrupt withdrawal

Parenteral nutrition is usually indicated in the following situation: A. Rectal abscess B. Cancer of the esophagus C. Bowel obstruction D. Malnutrition

C. Bowel obstruction

MODULAR SUPPLEMENTS

- A modular supplement contains a limited number of nutrients. Polycose, for example, contains only carbohydrate - Microlipid is an example of a lipid supplement. Modular supplements for protein include Resource Beneprotein and Pro-Mod Liquid Protein. - Modular supplements are available in a liquid or powder form and can be added to foods, other types of oral supplements, or tube feedings - Sometimes modular supplements are readily accepted if mixed with food

Administration of Medications

- A pharmacist should always be consulted before administration of medications via a feeding tube - To minimize or prevent complications, all health-care workers should be aware of potential drug-food interactions medications should never be added to the tube feeding formula because they can be physically incompatible with the product because of changes in the feeding's viscosity (thickness) or flow characteristics - Some medications may also cause the feeding to separate, granulate, or coagulate

Standard or "polymeric" formulas

- A standard or polymeric formula is a complete formula used when the GI tract is functional and the client needs all the essential nutrients in a specified volume - Dozens of such products are on the market. A complete supplement, such as Ensure, Boost, Jevity, or Nutren, should always be used when the formula is the sole source of nutrition

Counseling

- All clients should be evaluated for nutritional counseling. The assumption that a client is not expected to be discharged and therefore is not entitled to education is unjustifiable - Educating clients about nutritional concerns helps them assume responsibility for their own care, thus promoting self-esteem and a sense of worth.

Monitoring

- All clients should be reassessed or monitored at appropriate intervals. Most organizations include the required frequency of client monitoring in their standards of practice. Some clients in hospital ICUs require continuous monitoring - Other clients require daily, weekly, monthly, or quarterly reassessment as determined by preset guidelines. - The client-care conference (interdisciplinary conference) is a productive means of monitoring clients. Before the conference, health-care workers gather information that impacts the client's nutritional care, including: Initial nutritional screen or assessment - Present body weight and weight history - An accurate (recent) height, which should not be self-reported - A record of recent food intake or tolerance - Any changes in medical condition, including diagnoses and test results - Diet order - Family support (or lack of)

Diets for Diagnostic Procedures

- Many diagnostic procedures requiring dietary preparation are performed in hospitals. - Poor Client Preparation - Poor dietary preparation can force a client to have an expensive procedure repeated or postponed - Feces in the colon block the view of structures within the colon. In the absence of fecal material, the entire length of the colon can be visualized

Oral Delivery

- Most institutionalized clients are fed orally - Whenever possible, the client should be encouraged to eat foods, because this is an optimal way for the client not only to obtain nutrients but also to experience the normal psychological and physical pleasure associated with eating

Keypoints

- The nutritional care of clients is a joint responsibility of all team members. - How meals are distributed to clients and meal-service schedules are important for team members to know because they affect the administration of medications and the scheduling of clients for tests and procedures. - Nutrition screening is an important function of nurses and may determine that a client is at nutritional risk, requiring a nutritional assessment by a dietitian - Nutritional care includes four areas: assessing the client's need for nutrients, determining the best method for delivering nutrients, monitoring nutrient intake, and counseling clients about nutritional needs

Hypernatremia, Hyponatremia, Hypophosphatemia

1. Hypernatremia Assess the client's fluid and electrolyte status before treatment. Provide adequate fluids 2. Hyponatremia Assess the client's fluid and electrolyte status before treatment. Restrict fluids Supplement feeding with rehydration solution and saline Use diuretic therapy, as it may be beneficial 3. Hypophosphatemia Monitor serum levels Replenish phosphorus levels before refeeding

why it is important to carefully control the rate of delivery and volume of enteral formula delivered to a client

- The administration of an increasing amount of formula should be done slowly to prevent the development of GI disorders and increase the likelihood of avoiding interruption or discontinuation of the enteral feeding Nonsurgically inserted enteral tube feeding increases the risk of aspiration and is associated with the development of nosocomial pneumonia, which significantly increases morbidity and mortality in critically ill clients

The feeding pumps are set to deliver a given rate, volume, and amount of both enteral and parenteral feedings to a client

- The importance of connecting the enteral feeding to the tube that leads to the client's GI tract and connecting the intravenous solution to the tube that leads directly into the bloodstream cannot be overemphasized - Although this is primarily a nursing responsibility, all trained team members should make a habit of checking tube connections every time a client with two feeding routes is visited - The placement of a feeding tube into the wrong lead is called a misconnection

Assisted Feeding Versus Self-Feeding

- Some clients must be fed. Food should be offered in bite-sized portions and in the order that the client prefers. Clients should not be rushed - Talking with clients while feeding makes mealtime pleasant and signals that they are not being rushed - Staff members are encouraged to sit while feeding clients because this indicates a willingness to spend time with them and encourages relaxation - Some nursing staff members have found that they can enhance a client's food intake by mimicking normal eating behavior: 1. Sit behind the client. 2. Place your right arm over the client's arm (if you and the client are right-handed). 3. Place a fork or spoon with food in either the client's hand or your own hand (depending on the client's ability to do this maneuver). 4. Guide the client's hand to their mouth

Diet Orders

- The physician or designee is responsible for prescribing a diet for the client - Just as a medication cannot be administered to a client without a medication prescription, food or fluids cannot be served to a client without a physician's written diet order.

Special Diets

- The purpose of a special or modified diet is to restore or maintain a client's nutritional status by manipulating one or more of the following dietary aspects: - Nutrients such as protein, calcium, iron, sodium, potassium, and vitamin K may be increased, decreased, or held at a consistent level. - Kilocalories may be either restricted or increased. - Texture or consistency of foods may be modified. For example, if a client has dysphagia, a minced and moist diet with pre thickened liquids may be ordered. - Fiber may be restricted or increased depending on a client's gastrointestinal (GI) function. - Fluid may be pushed in the case of dehydration or limited for renal or cardiac diseases

iatrogenic Malnutrition

- The term iatrogenic malnutrition was first used in 1974 and refers to physician- or institution-induced malnutrition - Routine hospital practices such as extended periods of food or nutrient deprivation because of treatments, as well as diagnostic tests that interfere with the client's meal schedule or that cause a lack of appetite, are related to the high prevalence of malnutrition

Metabolic

1. Dehydration Assess the client's fluid requirements before treatment. Monitor the client's hydration status. 2. Overhydration Assess the client's fluid requirements before treatment. Monitor the client's hydration status; evaluate for a higher-caloric, low-volume enteral formula. 3. Hyperglycemia Initiate feedings at a low rate. Monitor blood glucose levels. Use hyperglycemic medication if necessary. Select a low-carbohydrate formula. Evaluate total kilocalories provided; overfeeding in a critically ill client exacerbates hyperglycemia.

TABLE 14-4 Feeding Complications and Prevention Strategies

1. Mechanical: - Tube irritation - Consider using a smaller or softer tube. - Lubricate the tube before insertion. 2. Tube obstruction - Flush tube per instructions. - Do not mix medications with the formula. - Use liquid medications if available. - Crush other medications thoroughly and infuse per instructions. - Use an infusion pump to maintain a constant flow. - Feeding should not be started until tube placement is radiographically confirmed

Hypercapnia, Hypokalemia, Hypokalemia

1. Hypercapnia Select low-carbohydrate, high-fat formula 2. Hypokalemia Monitor serum levels Supplement feeding with potassium if necessary 3. Hypokalemia Reduce potassium intake Monitor potassium levels

STANDARD OR POLYMERIC FORMULAS

- A standard or polymeric formula is a complete formula used when the GI tract is functional and the client needs all the essential nutrients in a specified volume - Dozens of such products are on the market. A complete supplement, such as Ensure, Boost, Jevity, or Nutren, should always be used when the formula is the sole source of nutrition - Some complete nutritional supplements are also designed for tube feedings; the consistency and flavor of a feeding designed to be tube-fed may not be acceptable to the client if fed orally

The following recommendations help reduce contamination *Continued

- Sterile, decanted formula or human breast milk (HBM) used for neonates has a limited hang time of 4 hours, with administration sets changed at that time - Store the formula in the refrigerator in a covered container - When a new supply of formula is received, place it in the rear of the storage area so that the older formula is used first - Check expiration dates carefully to ensure that expired product is not used for tube feedings - Administration sets for open system enteral feedings must be changed at least every 24 hours - A closed system bag or container is preferable for administering EN and may be hung for 24 to 48 hours per manufacturer guidelines

Gastrointestinal Function

- The GI tract should always be used to the extent possible - Oral supplements should be considered before tube feeding, and tube feeding should always be considered before PN - There is less septic morbidity, fewer infectious complications, and significant cost savings in critically ill adults who receive EN versus PN - Tube feeding is safer, less expensive, and more closely mimics normal feeding conditions than PN - Nutrients should be supplied intact rather than elemental or semielemental if the client has a normally functioning GI tract Intact nutrients are nutrients that are not hydrolyzed, and so the body must keep producing secretions and enzymes necessary for digestion, thereby forcing the GI tract to function

Disease-specific formulas

- The last group of oral supplements includes special formulas designed for clients with specific metabolic problems such as diabetes, kidney disorders, and liver disorders - These formulas are discussed in subsequent chapters. - Oral supplements are also used both in addition to or as a transition from enteral and parenteral feedings - When a client has ceased to consume foods orally for a time, a transition period is always necessary to reacclimate to oral feedings -This process can sometimes take a couple of days to months.

TABLE 14-3 Conditions Indicating a Tube Feeding

1. Client has mechanical difficulties that make chewing or swallowing impossible or difficult. Obstruction of the esophagus, weakness or nausea, mouth sores, throat inflammation 2. Client has an intestinal disease and cannot digest or absorb food adequately. Malabsorption syndromes 3. Client refuses to eat or cannot eat. Esophageal cancer, mechanical ventilation 4. Client is unable to consume a sufficient amount of food because of a clinical condition. Coma, serious infections, trauma victims, clients with large kilocalorie requirements

3. Mr. W has been receiving a tube feeding of Ensure via nasogastric tube for 3 weeks via a bolus infusion. He has just started to have loose stools (300 mL each—six today). You should first suspect which of the following to be responsible for the diarrhea? A. A new medication added to his treatment plan B. Bacterial contamination C. Intolerance to the bolus delivery method D. Lactose intolerance

A. A new medication added to his treatment plan

Which of the following is not a recommended procedure for administering medications through a tube feeding? A. Mix all of the medications together, crush thoroughly, mix with water, and add to the formula. B. If at all possible, use medications in the liquid form. C. Flush the tube with at least 30 mL of water before giving the medication and before resuming the tube-feeding formula.

A. Mix all of the medications together, crush thoroughly, mix with water, and add to the formula.

Ms. L has a jejunostomy. She was discharged from the hospital last week after receiving instructions on home care from the nutrition support service. The local pharmacy is out of the Vivonex formula she has been instructed to use. As the nurse, you recommend that: A. She substitute Ensure B. She substitute Polycose C. She contact the Nutrition Support Service for instructions D. She substitute a standard or polymeric formula

C. She contact the Nutrition Support Service for instructions.

proteins are either partially or totally what?

hydrolyzed - Partially hydrolyzed protein (small peptides) offers an advantage over totally hydrolyzed protein (single amino acids) - Peptides and free amino acids do not inhibit each other's transport across the GI tract, and absorption of nitrogen is actually improved by the inclusion of small peptides - Easier-to-digest fats include medium-chain triglycerides - Partially hydrolyzed fats include monoglycerides and diglycerides. - Elemental and semielemental formulas contain little lactose and residue and may be given orally or enterally through a tube - These formulas are expensive and for use with clients who have limited GI function or metabolic disorders - Because elemental and semielemental formulas are less palatable

contamination

- All tube feedings provide an excellent environment for the growth of microorganisms - When a client's tube feeding becomes contaminated with bacteria, the client receiving the feeding may become ill and suffer from nausea, vomiting, or diarrhea. - hospitals and nursing homes use only commercially prepared tube feedings that are packaged under sterile conditions - However, commercially prepared formulas can become contaminated if they are not handled properly after opening. To prevent contamination, first check the can for the correct product, expiration date, and any signs of contamination, such as swelling - If the can is swollen, notify your supervisor - Do not administer a feeding from a damaged can. Other cans in the same shipment should be checked for contamination. Good personal hygiene is essential - EN formulas must be prepared for client use in a clean environment using aseptic techniques - Sterile, liquid EN formulas should be used in preference to powdered, reconstituted formulas whenever possible

The following recommendations help reduce contamination

- Always properly wash hands and use disposable gloves. - Shake the container well and wipe down the lid with isopropyl alcohol, allowing it to dry before opening it. - Transfer the formula into a new administration bag or container. - Label the administration bag or container and any remaining formula carefully with the client's name, room number, the date and time the formula was opened, the amount in the container, the name of the product, the administration route and rate, and other pertinent information - Other information may include whether the formula contains vitamins or other additives. - Reconstituted formulas made in advance should be refrigerated immediately and, if not used, discarded within 24 hours of preparation; they should be exposed to room temperature for no more than 4 hours when hung for administration - Sterile, decanted formula has an 8-hour hang time

INTERMITTENT FEEDING

- An intermittent feeding means giving a volume of feeding solution (250 to 500 mL) from a feeding container or bag over 60 to 75 minutes with or without a feeding pump - It is normally used with gastric feedings in stable individuals who have normal gastric function, with a demonstrated tolerance to feeding, and who are able to protect their airway - The tube needs to be flushed before and after each feeding with 30 mL of water to minimize bacterial growth, to prevent contamination, and to minimize the chance the tube will clog - Many mobile clients prefer intermittent feedings because they are not continuously attached to the feeding pump - Children may be started with 25% of the goal volume divided by the desired number of feedings - The volume may be increased by 25% per day as tolerated, divided by the number of feedings

ELEMENTAL AND SEMI ELEMENTAL FORMULAS

- Another group of oral supplements includes elemental and semielemental. Examples of such formulas include Peptamen, Vital, and Vivonex - The nutrients in these formulas are easier to absorb because they are in their simplest form, small molecules, which require little digestion - For example, maltodextrins, corn syrup solids, oligosaccharides, and glucose polymers are rapidly hydrolyzed by maltase and oligosaccharidases, which are apt to be present in the small intestine in higher concentrations than lactase

Assessment

- Clients found to be at a nutritional risk need to have a complete nutritional assessment by a registered dietitian nutritionist (RDN), which may include the following items: 1. Height, weight, body mass index (BMI), and weight history 2. Laboratory test values 3. Food intake information 4. Potential food-drug interactions 5. Mastication and swallowing ability 6. Client's ability to feed himself or herself 7. Bowel and bladder function 8. Evaluation for the presence of pressure injury 9. Food allergies and intolerances 10. Any other factors affecting nutritional status, such as food preferences and cultural and religious beliefs about food 11. Determination of body composition, including results of a Nutrition Focused Physical Examination, to determine muscle strength and sarcopenia 12. Presence of severe burns, trauma, infection, edema, or other physiological stressors that increase nutrient needs and are likely to prolong hospital stay 13. Learning barriers such as hearing, mobility, language, need for interpreter, vision, speech, reading or writing skills, inability to follow instructions, cultural and religious barriers, learning disability, learning readiness (requests, accepts, or avoids information)

TRANSITION AND COMBINATION FEEDINGS

- Clients need a transition period from CPN to oral feedings. Some physicians prefer to wean clients from CPN by using a tube feeding -The client has both an enteral feeding line and CPN - Other physicians prefer to avoid the tube and wean clients orally - In the latter case, as the client's oral intake increases, the CPN solution is gradually withdraw - Expect clients who have been on CPN for a significant time to experience some difficulty with oral feedings (They may need much encouragement to eat)

CONTINUOUS FEEDING

- Continuous feeding is always recommended for formulas delivered directly into the small intestine. The prescribed formula volume is given continuously over 16 to 24 hours - One recommended rate is 30 to 50 mL/hour, increasing daily by 25 mL/hour to the rate necessary to meet energy needs. This gradual increase in the formula's volume gives the client's - GI tract a chance to adjust to the formula and helps prevent many complications that occur in tube-fed clients - Children should be started at 1 to 2 mL/kg/hour and advanced by 0.5 to 1 mL/kg/hour every 6 to 24 hours until the goal rate is achieved - For critically ill clients, a conservative recommendation of 10 to 40 mL/hour with advancement to the goal rate in increments of 10 to 20 mL/hour every 8 to 12 hours is recommended by ASPEN guidelines

Aspiration and regurgitation

- Elevate head of client's bed 30° to 45° at all times. - Discontinue feedings at least 30-60 minutes before treatments where head must be lowered (e.g., chest percussion). - If the client has an endotracheal tube in place, keep the cuff inflated during feedings. - If GRV is 500 mL or greater, a promotility agent should be considered as well as a feeding tube placed in the small bowel

Importance of Nutritional Care *Continued

- Malnutrition is associated with a 25% morbidity and a 5% mortality - Morbidity is defined as the rate of being diseased, whereas mortality is defined as the death rate - A malnourished client is more likely to be sicker and run a higher risk of death than a well-nourished client with the same diagnosis - Because malnutrition affects morbidity and mortality, it is also associated with a prolonged hospital stay - Malnutrition increases a person's susceptibility to infectious diseases; in return, having an infectious disease increases the likelihood of developing malnutrition - can be because of an inadequate intake, increased requirement, impaired absorption, or altered utilization of nutrients - These factors may impair the immune system, which negatively impacts recovery

Tube Placement

- Feeding tubes can enter the body through the nose or through a surgically made opening 1. A nasogastric (NG) tube runs from the nose to the stomach. 2. A nasoduodenal (ND) tube runs from the nose to the duodenum 3. A nasojejunal (NJ) tube runs from the nose to the jejunum - These types of tubes are for short-term use because of client discomfort and tissue irritation. - Long-term feeding devices should be considered when the need for enteral feeding is at least 4 weeks' duration in adults, children, and infants after term age; when a tube cannot be inserted through the nose (as in throat cancer), an ostomy (a surgically created opening) is created - An esophagostomy is a surgical opening into the esophagus through which a feeding tube is passed - A gastrostomy (called percutaneous endoscopic gastrostomy, or PEG) is a surgical opening in the stomach through which a feeding tube is passed; this is the most common tube insertion method. - A PEG tube can be placed percutaneously with the aid of an endoscope or surgically if the client is already undergoing abdominal surgery or has a condition that makes working with an endoscope difficult

In stable clients, serum levels of sodium, blood urea nitrogen, hemoglobin, and albumin are indicators of what status?

- Fluid status. Urine osmolality can be used to monitor hydration status - Urine osmolality is normally 50 to 1,400 mOsm, with a usual range of 300 to 900 mOsm and an average of 850 mOsm - Decreased osmolality indicates overhydration, and increased osmolality indicates dehydration - Fluid intake and output need to be recorded daily. Fluid intake should be at least 500 mL greater than output in clients who are neither overhydrated nor underhydrated - This 500-mL surplus is needed to cover insensible losses in feces and from the skin and lungs - Clinical signs of hydration tatus include skin turgor, the presence of axillary sweat, the condition of the mucous membranes, and the presence or absence of edema - Constipation is another possible sign of dehydration

CONTINUOUS FEEDING * Continued

- Flush the tube with 30 mL of water every 4 hours in continuously fed adults and after GRV checks (if any taken) and medication administration; flush with as little water as possible in infants and children - Sterile water should be used with medication administration, in immunocompromised clients, or in critically ill clients. - Allow no more than a 4-hour hang time for each bag of formula

Eating Environment

- Health-care workers need to create as pleasant an environment as possible immediately before and during mealtime - room should be checked for objectionable odors, sounds, and sights - full bedside commode or an emesis basin nearby discourages eating. In addition, the client should be prepared to eat when the tray arrives - Cleaning the client's hands and face helps the client become more enthusiastic about eating - client's bedside table should be cleared of all miscellaneous items, and unnecessary delays in serving the tray should be avoided - The client should be properly positioned to eat. This includes elevating the head of the bed (if the client's condition permits) and positioning the bedside table to the correct height. - Assistance with opening food packages or cartons may be required - Some clients may find the odor of food offensive. For these clients, it is best for the nurse not to uncover the food items directly in front of them, minimizing the risk of nausea - For these individuals, who are often oncology clients, open food trays in the hallway, or away from the client, to help dissipate the intense odors of hot foods

Parenteral Nutrition *Continued

- If an individual has major GI surgery and it is anticipated that it will not be possible to feed enterally 7 or more days postsurgically, PN should be initiated 5 to 7 days after the surgery. - If an individual is unable to meet more than 60% of energy requirements after 7 to 10 days by enteral route alone, PN is normally used. - Peripheral parenteral nutrition (PPN) means to feed the client via a vein away from the center of the body in a line terminating in a peripheral site - In central parenteral nutrition (CPN), the client is fed via a central vein - Clients are also fed via a central line that has been inserted peripherally and threaded into the subclavian or jugular veins. This is called a peripherally inserted central catheter or PICC line

Home Parenteral Nutrition (HPN)

- Increasingly, clients are discharged on CPN. These clients need adequate follow-up by either the hospital or a community home-health agency - The pharmacist is responsible for the storage of PN solutions in most institutions - Health-care organizations that provide nursing services related to home infusion of PN must establish mechanisms for periodic reassessment of knowledge and technique use by clients and caregivers

Nutritional Care Services

- Institutions vary in the types of nutritional services they offer clients - A large teaching hospital or medical center frequently has nutrition professionals on staff who specialize in treating particular types of clients - A critical care dietitian, for example, has special training to assess, plan, implement, and counsel clients in high-risk stages of trauma, disease, and conditions that affect nutritional support - In such settings, other health-care workers can rely on the critical care dietitian to provide technical support.

The acronym MARK can be used to guide the steps for monitoring tube placemen

- M is for marking the tube at the exit with an indelible marker; A is for anchoring the tube; R is for reassessment of tube placement; and K has two meanings, for keeping pressure off the skin and knowledge needed to ensure safe practice of institutional policies - Tube migration places the client at risk for aspiration because the tube may move into the trachea - The client is also at risk if they regurgitate the feeding - Regurgitation means to cause to flow backward. If the feeding backs up into the client's lungs, a lung infection can develop. - When clients inhale fluids regurgitated from the stomach, they may develop aspiration pneumonia - Aspiration is the state in which a substance has been drawn up into the nose, throat, or lungs - Nonsurgically inserted enteral tube feeding increases the risk of aspiration and is associated with the development of nosocomial pneumonia, which significantly increases morbidity and mortality in critically ill clients.

Importance of Nutritional Care

- Malnutrition associated with acute and chronic disease is common in hospital settings - Acute means that the illness has a rapid onset, severe symptoms, and a short course - Chronic means that the illness has a long duration. - The presence and importance of malnutrition have been increasingly recognized throughout the world - Malnutrition is one of the most common conditions affecting the care of hospitalized clients - The prevalence of adult malnutrition is estimated to be up to 50% of hospitalized individuals - Malnutrition is associated with a longer length of stay, a higher cost of hospitalization, increased risk for readmission, and increased mortality

reasons for the high incidence of malnutrition in institutionalized clients and the interventions nurses can perform to combat malnutrition.

- Most institutionalized clients are fed orally. Whenever possible, the client should be encouraged to eat foods, because this is an optimal way for the client not only to obtain nutrients but also to experience the normal psychological and physical pleasure associated with eating - Nursing actions can affect the nutritional health of institutionalized clients. The following behaviors minimize the likelihood of malnutrition: - Recording height and weight - Regular communication among nurses, physicians, dietitians, and other health-care workers - Food-tray viewing/monitoring and documentation of client's food intake - Careful food handling and sanitation practices for oral and enteral feedings - Knowledge of the importance of good nutrition, nutritional supplements, and the composition of vitamin mixtures - Monitoring the length of time clients are NPO, on liquid diets, and on intravenous feedings of only glucose - Appreciation of the role of nutrition in the prevention and recovery from infection - Recognition of the increased nutritional needs because of injury or illness - Monitoring of stool frequency, urinary losses, losses by suction tubes, drainage, and so on - Recording of weight at regular intervals - Monitoring of behavior patterns, vomiting, and any unusual comments clients make about food - Monitoring of client fluid intake and output

Keypoints *Continued

- Nutrients can be delivered to clients orally, enterally via a feeding tube, or parenterally - One principle is followed when selecting a feeding route: If the GI tract works, use it to maximum capability. - Oral feedings should be considered before EN should be considered before PN - PN can be delivered peripherally or centrally. - Clients on either EN or PN need to be *closely monitored

Identify three routes used to deliver nutrients to clients and potential complications with two of these routes

- Nutrients can be delivered to the client orally in foods or supplements, enterally by feeding tube, or parenterally through veins - Enteral nutrition (EN) means the feeding of an appropriate formula or liquid via a tube to a client's GI tract - Parenteral nutrition (PN) designates that nutrients are being provided via an intravenous route.

Methods of Nutrient Delivery

- Nutrients can be delivered to the client orally in foods or supplements, enterally by feeding tube, or parenterally through veins - Enteral nutrition (EN) means the feeding of an appropriate formula or liquid via a tube to a client's GI tract - Parenteral nutrition (PN) designates that nutrients are being provided via an intravenous route. feeding pumps are set to deliver a given rate, volume, and amount of both enteral and parenteral feedings to a client - The importance of connecting the enteral feeding to the tube that leads to the client's GI tract and connecting the intravenous solution to the tube that leads directly to bloodstream cannot be overemphasized - all trained team members should make a habit of checking tube connections every time a client with two feeding routes is visited The placement of a feeding tube into the wrong lead is called a misconnection

Screening, Assessment, Monitoring, and Counseling

- Nutritional care is a responsibility of many health-care team members - The nurse is usually the first team member to interview and assess the client, often before the physician visits the client - The physician or physician assistant completes a physical examination of the client, orders necessary treatments and diagnostic procedures, and provides either a diagnosis or a tentative diagnosis - The diagnosis may change after the diagnostic tests are completed - The nurse, the physician, or the physician assistant usually makes referrals to other team members

Screening

- Nutritional screening is completed by established criteria within the institution based on the client's needs and conditions, but normally within 24 hours of admission to an acute care facility (The Joint Commission, 2020) - The recommendation for critically ill clients admitted to the intensive care unit (ICU) is for immediate nutritional assessment - A health technician or nurse may use a series of questions, often in the form of a predetermined screening tool, that rates a client's potential nutritional risk - Changes in weight or appetite and the presence of nausea, vomiting, dysphagia (difficulty swallowing), or disease state (such as diabetes, obesity, hypertension, cancer, etc.) are reviewed

Parenteral Nutrition

- PN, in which nutrients are delivered to the client through the veins (intravenously), is the third means of feeding. - PN is a prescription drug accounting for nearly 20% of all injectable drug-related errors and is often ranked in the top 10 medication errors - PN is normally used in acute care settings in the following circumstances - *In a previously healthy individual admitted to an ICU after 7 days of hospitalization when EN is not feasible, PN is normally used. - If there is high nutrition risk and severe malnutrition, and if it is not possible to feed enterally, PN should begin as soon as possible, beginning at 80% of estimated energy needs but with adequate protein (1.2 g protein/kg/d or more) - After stabilization, 100% of energy requirements should be provided

Assisting the Disabled Client

- Partial assistance may include opening milk cartons and plastic bags containing condiments and eating utensils, buttering bread, and cutting meat - Visually impaired clients may be able to feed themselves when they know where the food is on the plate. - The usual technique is to describe food placement in terms of hours on a clock face - Some clients can feed themselves but may be slow and have difficulty with fine motor skills - Adaptive utensils, plates, and cups may be helpful for these clients - A large napkin under the chin, or clothing protection bibs, may assist in keeping the client dry and clean while eating - Offering hot beverages in small amounts, in appropriate cups, may minimize the likelihood of an accident - Health-care workers should evaluate clients who cannot feed themselves and encourage them to remain as independent as possible in all the activities of daily living, including eating - Some clients' inability to feed themselves may be related to neuromuscular disabilities - The OT has special training in the selection and fitting of eating devices to assist such clients

Tube displacement

- Place a black mark at the point where the tube, once properly placed, exits the nostril - Replace the tube and obtain a physician's order to confirm with x-ray imaging

Misdiagnosis

- Poor dietary preparation can lead to a misdiagnosis. For example, a blood sample for a fasting blood glucose (FBS) test should be drawn on a fasting individual, that is, one who has not had any food or beverages (with the exception of sips of water) by mouth for at least 8 hours before the blood draw - If the client eats before the procedure, their blood glucose level may be elevated, and this elevation may cause a misdiagnosis of diabetes, which may cause a client unnecessary anxiety, medical treatment, and expense

Administration

- Tube feedings can be administered continuously, intermittently, or by bolus - Clogging of the tube occurs significantly more often with continuous rather than intermittent feedings. ASPEN guidelines recommend the following for when administering EN: - Evaluate all clients for risk of aspiration. - Ensure that the feeding tube is in the proper position before initiating feeding - Ensure the client's head is elevated at a minimum of 30° to 45°. - If gastric residual volume (GRV) is checked, feeding should not be held for GRV less than 500 in the absence of other signs of intolerance. GRV checks are not recommended for ICU clients - Flush tubes according to guidelines given for the type of feeding - Plan the feeding schedule to maximize delivery of the daily feeding volume required by the client - A volume-based feeding protocol can accommodate interruptions to the feeding schedule and give the nurse latitude to meet the client's feeding goal - In critically ill clients, the volume of EN formula should be targeted at 80% of the required amount in the first week of tube feedings

CPN and PICC Lines

- When nutrients are infused into a terminal central vein, PN is often referred to as CPN - The superior vena cava, one of the largest-diameter veins in the human body, is commonly used for CPN, and CPN can deliver greater nutrient loads because the blood flow in the superior vena cava rapidly dilutes these solutions 1,000-fold - Concentrations for both dextrose and amino acids are determined by the client's needs. - A line *inserted peripherally but threaded into a central vein is CPN. - Many metabolic complications are possible with CPN. For example, rapid shifts of potassium, phosphorus, and magnesium from the intercellular compartment to the intracellular compartment result in a lowering of nutrient concentrations in the serum - initial laboratory tests rapidly fluctuate during the course of treatment - Immediate replacement of potassium, phosphorus, and magnesium is indicated if the corresponding laboratory values of these nutrients fall below normal

Modular Supplement

- a modular supplement contains a limited number of nutrients. Polycose, for example, contains only carbohydrates - Microlipid is an example of a lipid supplement. Modular supplements for protein include Resource Beneprotein and Promod Liquid Protein. - Modular supplements are available in a liquid or powder form and can be added to foods, other types of oral supplements, or tube feedings - Sometimes modular supplements are readily accepted if mixed with food.

Elemental and semi elemental formulas

- elemental and semi elemental formulas contain little lactose and residue and may be given orally or enterally through a tube - These formulas are expensive and for use with clients who have limited GI function or metabolic disorders - Because elemental and semi elemental formulas are less palatable than standard feedings, client acceptance of these as oral feedings is often a problem.

A PEG tube can be how?

- percutaneously with the aid of an endoscope or surgically if the client is already undergoing abdominal surgery or has a condition that makes working with an endoscope difficult. - A PEG tube may be used for feedings within 4 hours or less of placement in adults and children - Percutaneous endoscopic jejunostomy (PEJ) tube placement is generally reserved for clients who are not candidates for a PEG. - example, a client who has had a gastrectomy (stomach removal) procedure requires a PEJ tube placement. A PEJ tube is also indicated for clients prone to aspiration

Methods for Team Members to Combat Iatrogenic Malnutrition

1. Nursing actions can affect the nutritional health of institutionalized clients. The following behaviors minimize the likelihood of malnutrition: 2. Recording height and weight 3. Regular communication among nurses, physicians, dietitians, and other health-care workers 4. Food-tray viewing/monitoring and documentation of client's food intake 5. Careful food handling and sanitation practices for oral and enteral feedings 6. Knowledge of the importance of good nutrition, nutritional supplements, and the composition of vitamin mixtures 7. Monitoring the length of time clients are NPO, on liquid diets, and on intravenous feedings of only glucose 8. Appreciation of the role of nutrition in the prevention and recovery from infection 9. Recognition of the increased nutritional needs because of injury or illness 10. Monitoring of stool frequency, urinary losses, losses by suction tubes, drainage, and so on 11. Recording of weight at regular intervals 12. Monitoring of behavior patterns, vomiting, and any unusual comments clients make about food 13. Monitoring of client fluid intake and output

Common Diet Orders

1. Some common diet orders are for clear liquid, full liquid, soft, and general or regular - A clear-liquid diet is any transparent liquid that can be poured at room temperature For example, gelatin, some juices, broth, tea, frozen ices, and coffee are clear liquids. A clear-liquid diet is nutritionally inadequate and normally limited in duration - Clear-liquid nutritional supplements, however, are available. 2. A full-liquid diet is any liquid that can be poured at room temperature. Milk, custard, all fruit juices, ice cream, strained soups, and all items allowed on the clear-liquid diet are allowed on most full-liquid diets -The major difference between a clear-liquid and a full-liquid diet is that the latter contains milk and milk products - The nurse may be responsible for determining the client's tolerance for food just before tray delivery - This last-minute determination of client tolerance is necessary for many clients because of fluctuating medical status

A client diagnosed with COVID-19 is in the ICU, positioned in a prone position, and receiving supplemental oxygen. Which of the following demonstrates the Safe and Effective Nursing Care you expect that you would be following regarding the provision of nutritional care? A. Work with the other health-care team members to screen the client nutritionally and provide relevant information for the nutritional care of the client. B. Provide oral feeding and initiate a tube feeding when documentation indicates the client is not eating the required kilocalorie and protein needs to battle the disease. C. Document in the medical record the client's intake of all food, supplements, and enteral tube feeding products during your shift. D. Provide bolus feedings for the tube feeding to mimic meals.

A. Work with the other health-care team members to screen the client nutritionally and provide relevant information for the nutritional care of the client.

Among the following, diarrhea in a tube-fed client is most likely related to: A. Continuous-infusion feeding B. Contamination C. Fluid deficiency D. Insufficient kilocalories

B. Contamination

Mr. J, 58 years old, visits his physician with a complaint of abdominal pain. He is scheduled for a diagnostic work-up, which will include a barium enema (x-ray study of his colon). Before this procedure, the nurse should instruct the client to: A. Eat a large breakfast on the day of the examination, such as orange juice, cereal, toast, scrambled eggs, and milk. B. Drink ample fluids on the morning of the examination, including at least 12 ounces of juice, 1 cup of gelatin, and broth. C. Take nothing orally after midnight on the day of the examination and consume only gelatin; clear broth; tea; coffee; and grape, apple, or cranberry juice on the day before the examination. D. Drink milk, juices, and coffee and eat only strained cream soups, ice cream, and gelatin on the day before the examination, and take nothing orally after midnight.

C. Take nothing orally after midnight on the day of the examination and consume only gelatin; clear broth; tea; coffee; and grape, apple, or cranberry juice on the day before the examination

Potential Complications for Bolus Feeding

Complications fall into three categories: 1. Mechanical 2. Gastrointestinal 3. Metabolic - Sensitivity to the osmolality of oral supplements and tube feedings varies from one individual to another - All clients need a period of adjustment to a high-osmolality formula - Most clients are able to eventually develop a tolerance to a high-osmolality formula; some clients, however, are more likely to develop symptoms of intolerance. Such clients include those who: 1. Are debilitated 2. Have GI disorders 3. Are preoperative and postoperative 4. Have a GI tract that has not been challenged by food for a significant period 5. Have newly inserted surgically placed tubes (PEG and PEJ)

Discuss the kinds of commercial formulas available for oral and enteral feedings

Four types of supplements are used for oral or enteral feedings: Modular supplements Standard or "polymeric" formulas Elemental and semi elemental formulas Disease-specific formulas

Liquid supplements can include:

Milk Milkshakes Instant breakfast drinks Commercially prepared beverages