CHAPTER 5 PATIENT CARE SKILLS

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CHAPTER 5PATIENT CARE SKILLS
Assisting with Enteral Nutrition
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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.

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• Enteral nutritiongiving 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

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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

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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

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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.

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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

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FeedingsScheduled

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

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

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

• 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.

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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 Fowlers 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

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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

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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

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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 gt24 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

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Complications Aspiration

• 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

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General care measures

• Provide oral care

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General care measures

• Monitor bowel movements

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General care measures

• Prevent complications
• Aspiration
• HAI
• Dehydration
• Dumping syndrome

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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

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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-Fowlers position for feeding
  and remain for 1 hour after.
• never left side lying position

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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

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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

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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

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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.
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• 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.

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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

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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)

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Skill 1

• - Giving a tube feeding
• -see procedure in the chapter

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Skill 2

• -Remove a nasogastric tube
• -see procedure in the chapter

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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

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Taking a blood glucose

• Skill practice

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

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

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• 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

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• 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)

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• 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

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Nursing Assistants 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 patients blood glucose levels

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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

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PERFORM A SKIN PUNCTURE
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Key Terms Genitourinary Skills

1. Ostomy
2. loop stoma
3. double barrel stoma
4. end stoma
5. enterostomal therapy
6. ileostomy
7. effluent
8. colostomy
9. irrigation

• stenosis
• perforation
• prolapse
• diverticulitis
• flatus
• herniation
• necrotic
• peristomal

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Ostomy Care

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

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Reasons for using a stoma

• Genetic defect
• Inadequate blood flow
• Removal of necrotic section
• Traumatic adnominal injury
• Disease process
• Cancer
• Diverticulitis
• Polyposis
• Crohns disease
• Ischemic bowel
• Ulcerative colitis

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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

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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
• Proximalfunctioning part
• Distalnon-functioning part
• May be permanent or rejoined when healed

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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

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Anatomy review Small 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.

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Anatomy review Large 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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Choosing a pouch system

• DETERMINING FACTORS
• 1. Type of effluent
• liquid of fairly constant would take a drainable
  pouch
• formed would take a security pouch with a closed
  end
• 2. Presence of disabilities
• - a patient with limited manual dexterity would
  use a one-piece system
• - a two-piece system for those who are mobile
  and able to reach the ostomy site without
  difficulty

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Choosing a pouch system (cont)

• 3.Personal preference
• -pt must feel comfortable and capable
• 4. Physiology
• -size and shape of the stoma
• -size and contour of the abdomen
• -peristomal skin condition -physical
  activities/ manual dexterity
• -opening of the skin barrier for the stoma will
  continue for six to eight weeks

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Changing a pouch

• See procedure sheet

• Equipment needed
• written instructions for the patient
• clean towel
• washcloth
• soap and water
• measuring guide
• flange
• pouch
• pouch clamp
• pen
• scissors
• protective skin barrier paste
• disposable bag

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ENTEROSTOMAL THERAPY

• -enterostomal therapy occurs after the stoma is
  placed during surgery (therapy to help the
  patient with care of the stoma and peristomal
  area)
• -postoperatively the enterostomal nurse (ET
  nurse) is responsible for the preparation and
  application of the post-op pouch and the
  following responsibilities
• remeasure the stoma each time the pouch is
  changed
• Check the pouch for leakage
• Any complaints of itching or burning should be
  assumed as leakage
• Empty the pouch when it is one third full of
  stool or flatus (air in the intestine that causes
  gas) high output post-op, then 600 to 1000cc for
  2 months

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ENTEROSTOMAL THERAPY

• Monitor the stoma
• -normalred, moist, and shiny, with skin intact
• Document observations in the chart
• -amount of effluent
• -appearance of stoma
• -appearance of the peristomal area

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SKILL 3

• Perform change a pouch

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BELLWORK

• Explain the difference between a colostomy and an
  ileostomy (1 pt)
• How is the type of pouch system determined. (2
  pts)
• Define effluent. (1 pt)
• Determine the difference in the effluent from a
  colostomy and an ileostomy (1 pt)

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Patient Education

• -teach basic anatomy and physiology, self care
  techniques
• how to empty the pouch
• how to measure the stoma
• how to cut the opening in the skin barrier
• how to apply the pouch and clamp
• -teach from simple to complex.
• -irrigation (cleansing the colon by flushing with
  water) may be taught but will depend on the
  patient and bowel function

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SIGNS OF COMPLICATIONS AND OTHER PROBLEMS

• -most require immediate attention
• skin breakdown
• blockage
• obstruction
• continuous stomal bleeding
• prolapse (a falling or dropping down the
  intestine)
• herniation (when the intestine protrudes into the
  abdomen)
• stenosis (constriction or narrowing of the
  opening)
• perforation (a hole made through a part)
• dehydration

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Diet

• a dietician is needed for educating the patient
  post-op.
• foods given post-op depend on the ostomy site
• advise to avoid foods that cause excessive odor,
  flatus, constipation, or diarrhea
• new foods introduced one at a time, until effects
  are known

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Bulk Forming Foods

• celery
• Chinese food
• nuts
• coconut
• wild rice
• popcorn
• whole grains
• coleslaw
• seeds/kernels
• raw veggies
• raw fruits

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Odor Forming Foods

• fish
• eggs
• asparagus
• onions
• garlic
• beans
• peas
• cabbage
• turnips

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Gas Forming Foods

• cabbage
• beans
• Mexican
• Dairy
• Mushrooms
• Beer
• Carbonated drinks
• Pickles
• Eggs
• Onion
• Broccoli
• Corn
• Yeast
• Spinach

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Diarrhea

• green beans
• broccoli
• spinach
• raw fruit
• fried foods
• highly seasoned foods

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Foods that Change color of stool

• beets
• tomatoes
• strawberries
• spaghetti sauce

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Control diarrhea

• bananas
• applesauce
• boiled rice
• boiled milk
• tapioca
• yogurt
• buttermilk
• peanut butter

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Psychological complications

• depression
• withdraw from activities
• decreased self-esteem
• change of self image

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QUESTIONS ????????????