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CHAPTER 5 PATIENT CARE SKILLS

CHAPTER 5 PATIENT CARE SKILLS. Assisting with Enteral Nutrition. Assisting with Enteral Nutrition. Objectives Define the key terms in this chapter Describe the routes for enteral nutrition Explain the purpose of enteral nutrition Describe how to handle formula for enteral nutrition

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CHAPTER 5 PATIENT CARE SKILLS

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  1. CHAPTER 5PATIENT CARE SKILLS Assisting with Enteral Nutrition

  2. Assisting with Enteral Nutrition Objectives • Define the key terms in this chapter • Describe the routes for enteral nutrition • Explain the purpose of enteral nutrition • Describe how to handle formula for enteral nutrition • Explain the difference between scheduled and continuous feedings • Explain how to prevent aspiration and regurgitation • Identify the signs and symptoms of aspiration • Describe the comfort measure that relate to enteral nutrition • Explain the safety precautions involved in giving tube feedings • Identify the reasons for removing a nasogastric tube • Perform the procedures described in this chapter: giving a tube feeding, removing a nasogastric tube.

  3. Enteral nutrition=giving nutrients through the GI tract. • Feeding tube inserted into the stomach or small intestine. • used when food can't pass normally from the mouth into the esophagus and into the stomach

  4. Conditions that are common • cancer of the head neck, or esophagus • trauma to face, mouth, head or neck. • surgery to face, mouth, head, or neck. • coma • dementia

  5. Types of feeding tubesTemporary A. nasogastric tube (NG) • inserted through the nose into the stomach. • performed by a nurse or doctor B. nasointestinal tube (NI) • inserted through the nose into the duodenum or juejunum of the small intestine • doctor or RN performs procedure

  6. Types of tube feedingsPermanent A. gastrostomy • opening into the stomach created surgically B. jejunostomy • inserted into the middle part of the small intestine • created surgically C. percutaneous endoscopic gastrostomy (PEG ) tube • inserted with an endoscope through the mouth and esophagus into the stomach. • incision is made through the skin and into the stomach, tube is inserted through the incision.

  7. Methods of Administering • Syringe • Uses a 60 ml syringe • Flow rate is controlled by gravity • Feeding bag • Formula is poured into a bag hung from IV pole • Flow rate is adjusted by the height of the bag on the pole • Feeding pump • Formula poured into a bag and tubing is threaded through a machine • Rate is controlled by the pump

  8. FeedingsScheduled • May be Scheduled or continuous feedings • ordered by the doctor which way to be given

  9. FeedingsBolus intermittent feeding receives a large amount of formula over a relatively short period of time.

  10. FeedingsContinuous • require feeding pumps • can be nasointestinal or jejunostomy tube feedings • formula is to be kept at room temperature: cold can cause cramping • formula is added every 3 to 4 hours • never add new formula to formula in the bag d/t contaminated • never hang more than 4 hours to prevent the growth of microorganisms

  11. FeedingsCyclic feeding receives small amounts of formula constantly for 8to 12 hours; then the person is disconnected from the feeding pump.

  12. Feedingsscheduled • usually given four times a day • given with a syringe or feeding bag • approximately 400 ml over 20 minutes • amount and rate like a regular meal.

  13. Children and ElderlyChildren • NG, G tube and PEG tube feedings more common • usually scheduled not continuous • position for feeding would be in your lap to allow for comfort of the child • elevate the head and chest • position on right side or Fowler’s position for 1 hour (usually directed by RN) if able • amount of formula and position for feeding directed by RN • infants get pacifiers to suck on during the feeding to allow normal sucking reflex, comfort and reduce crying • note cramping, vomiting, discomfort

  14. Children and ElderlyElderly • increased risk of regurgitation d/t slowing of digestion and stomach emptying • less formula and longer feeding time than other adults • May be unable to stay on side or back for longer than 1 hour

  15. Formulas Many different types but common factors in each • Most contain protein, carbohydrates, fat, vitamins, and minerals. • Commercially prepared or prepared by dietary department in house • Can provide an environment for the growth of microorganisms. • Must not contaminate when handling

  16. Preventing contamination of formulas • Wear gloves when preparing or handling formula • replace soiled gloves as necessary • Do not use dented or damaged cans. • Check the expiration date on commercial formulas. • Check the date on formulas prepared by the dietary department and Discard if >24 hours • Wash cans or bottles before opening them. • Label cans or bottles with the time and date opened. • Refrigerate open cans or prepared formula • Clear the tube before and after the feeding using 30-50 cc of water or other fluid per facility policy • Counted as part of the pts intake

  17. ComplicationsAspiration • a major complication of NG and NI tubes • Defined as breathing of fluid or an object into the lungs • placement can cause the tube to slip into the respiratory tract. • must be determined by an x-ray to assure that tube is in the stomach or SI • may move out of place with coughing, sneezing, vomiting, suctioning, and poor positioning. • ***RN checks for placement before every scheduled tube feeding, continuous every 4 to 8 hours by aspirating GI secretions

  18. General care measures • Provide oral care

  19. General care measures • Monitor bowel movements

  20. General care measures • Prevent complications • Aspiration • HAI • Dehydration • Dumping syndrome

  21. Aspiration -signs and symptoms • nausea • discomfort during the feeding • vomiting • diarrhea • distended abdomen • coughing • complaint of indigestion or heart burn • redness, swelling, drainage, odor, or pain at site of ostomy • elevated temp • respiratory distress • increased pulse • complaints of flatulence

  22. ComplicationsRegurgitation • backward flow of food from the stomach into the mouth • can occur with NG, G, PEG tubes • less often with NI, J tube • common causes 1. delayed stomach emptying 2. overfeeding • prevention -sitting or semi-Fowler’s position for feeding and remain for 1 hour after. *******never left side lying position*******

  23. Comfort measures • usually NPO, causes dryness of mouth, lips, sore throat • may be allowed hard candy or gum, check care plan • frequent oral hygiene • lubricant for the lips • mouth rinses • Nose and nostrils are cleaned q 4 to 8 hours • secure NG tube with tape to nose and gown to relieve pressure on nose

  24. Giving a tube feeding You may assist the RN and then complete on own as AP and PCT guidelines to follow before giving a tube feeding • must be allowed by the state • be in job description • by educated and trained to perform • know how to use the equipment at the facility • review the procedure with the RN • RN available to answer questions • RN checks tube placement ***patient may have IV infusions, drainage tubes, and breathing tube as well as GI tube. MUST KNOW THE DIFFERENCE****

  25. Report to the Nurse Immediately • Abdominal pain or bloating • Cyanosis • Dry mucus membranes • Nausea or vomiting • Decreased or very concentrated urine • Coughing or wheezing • Diarrhea or constipation • Difficulty breathing • Fever • Low reading on pulse oximeter

  26. Total Parenteral Nutrition How TPN Differs From Enteral Nutrition TPN bypasses the digestive tract and delivers the nourishment directly into the bloodstream and is not digested. TPN is administered through a central line into one of the two large veins that empty directly into the heart.

  27. TPN is a solution that contains nutrients in their smallest form. • Patients who receive TPN are very ill, injured, or may be recovering from surgery, especially gastrointestinal, and may not be able to tolerate food in the digestive tract.

  28. Removing a nasogastric tube • removed when the person can eat and swallow. • must be free of nausea and vomiting • MD orders the removal of the tube • check job description and state regulations • Use Standard Precautions and The Bloodborne Pathogen Standard guidelines • report observations • any bleeding • pt tolerance of procedure • pain or discomfort during or after procedure

  29. Bellwork 1. List two ways that a Patient Care Technician can prevent contamination of enteral nutrition formulas (1 pts) 2. Identify the following tubes by their placement and insertion site (2 pts) nasogastric tube gastrostomy tube jejunostomy tube PEG tube 3. Define aspiration and give a common cause for its occurrence (1 pts) 4. Explain the difference between continuous feeding and scheduled feeding (1 pts)

  30. Skill #1 - Giving a tube feeding -see procedure in the chapter

  31. Skill #2 -Remove a nasogastric tube -see procedure in the chapter

  32. SKIN PUNCTURES • = penetration of the capillary bed in the dermis of the skin with a lancet or other sharp device to collect a blood specimen • =especially important in pediatrics • =fingers in adults and children older than 2 • =heels of infants

  33. Taking a blood glucose • Skill practice

  34. Equipment • Lancet • microcollection tube/container • microhematocrit tube

  35. Site selection criteria-skin puncture • warm, pink, or normal color • free of scars, cuts, bruises, or rashes • no cyanosis • no edema

  36. Infants • heel recommended site for infants less than 1 year • precautions: DO NOT PUNCTURE • deeper than 2.o mm • through previous puncture sites • the area between the imaginary boundaries • the posterior curvature of the heel • in the arch causing injury to nerve, tendons, and cartilage • areas of the foot other than the heel

  37. older children and adults • palmar surface on the distal segment of finger • usually nondominant hand • fleshy central portion, slightly to side and tip • perpendicular to whorls(grooves in the fingerprint)

  38. DO NOT PUNCTURE: • Side or tip of the finger • Parallel to grooves of the fingerprint • causes blood to run down the finger rather than form a round drop • The index finger • more callused and harder to poke • used more often and cause more pain • Fifth or little finger • thinnest tissue • Fingers of infants and very young children

  39. Nursing Assistant’s Role • Check that the dressing over the central line insertion site is clean and dry • Notify the nurse if the dressing becomes wet, soiled, or loose • Monitor the patient’s blood glucose levels

  40. Monitoring Glucose Levels • The TPN solution is very concentrated and contains a great deal of glucose • It is delivered directly into the bloodstream, causing the body to have difficulty monitoring and regulating the blood glucose level • Glucose levels should be monitored every 6 hours • Patients taken off TPN should continue to have their glucose levels checked for hypoglycemia

  41. PERFORM A SKIN PUNCTURE

  42. Ostomy loop stoma double barrel stoma end stoma enterostomal therapy ileostomy effluent colostomy irrigation stenosis perforation prolapse diverticulitis flatus herniation necrotic peristomal Key Terms Genitourinary Skills

  43. Ostomy Care • Ostomy= a surgically created opening that serves as an exit site for fecal matter. • Colostomy=an opening created anywhere along the large intestine or colon • Ileostomy=an opening into the ileum or terminal portion of the small intestine

  44. Reasons for using a stoma • Genetic defect • Inadequate blood flow • Removal of necrotic section • Traumatic adnominal injury • Disease process • Cancer • Diverticulitis • Polyposis • Crohn’s disease • Ischemic bowel • Ulcerative colitis

  45. TYPES OF STOMAS • Loop stoma • Loop of intestine is brought to the abdominal surface • Usually temporary, closed in 2-3 months • Bowel function returns to normal

  46. TYPES OF STOMAS • Double barrel stoma • A portion of the bowel is removed and both ends are brought to the surface to form two stomas • Proximal=functioning part • Distal=non-functioning part • May be permanent or rejoined when healed

  47. TYPES OF STOMAS • End stoma • Created when disease or pathology is present • Affected portion and all parts below it are removed to prevent further spread • Stoma will be proximal to affected area • Permanent or temporary

  48. Anatomy reviewSmall intestine -primary functions 1.digestion 2. some absorption -26 ft. long and one inch in diameter -parts • duodenum • jejunum • ileum -effluent (output or drainage from a stoma) is semi-liquid and caustic to the skin.

  49. Anatomy reviewLarge intestine -two primary functions • absorption of water • transportation and storage of fecal matter -6 to 8 ft long and 2 ½ inches in diameter -parts • ascending colon • transverse colon • descending colon • sigmoid colon -effluent ranges from liquid to semi-formed to formed depending on the location -not as corrosive as to the skin

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