Overview of Nursing Care Of Patients Receiving

Objectives
The learner will be able to:
discuss the indications and contraindications for the use of parenteral vs enteral nutrition discuss the nursing considerations related to patient care when administering enteral and parenteral nutrition be aware of some of the types of enteral nutrition tubes available discuss some of the possible complications that could arise from both

Parenteral and Enteral Nutrition

Eleanor Griffiths,CNE
Capital District Health

Parenteral Nutrition
is the intravenous infusion of nutrients, including: amino acids glucose fat emulsions vitamins electrolytes minerals trace elements water

Indications for PN:

Patients who are moderately to severely malnourished, in negative nitrogen balance GI tract is impaired
obstruction, ileus, surgery, fistulas, short bowel syndrome

Acute pancreatitis or GI bleed Acute episodes of Crohns/ Colitis Severe burns, trauma, liver or renal disease Radiation enteritis and terminal illness

Modes of Administration
1. Peripheral Parenteral Nutrition [PPN]
iso-osmotic, dextrose<10%

Parenteral Nutrition
Large volume medication Record it as a medication Need to perform a double check to ensure accuracy Requires a 0.22 micron bacterial retentive filter Follow aseptic technique when caring for lines

2. Central Parenteral Nutrition [CPN]

commonly referred to as TPN hypertonic, dextrose>10%

Guidelines:
Dietician consultNutritional assessment DR's order sheet [starting/stopping protocols]

Guidelines
Baseline lab work, ht, & wt.
CBC, E+, INR, Bilir, Creat, BUN, Alk Phos, Ca+, Albumin, AST, ALT, Mag, Phos, Glucose, Pre-Albumin

Routine monitoring:
lab work (once-twice/week): glucose checks (BID x48hrs, then if needed initiate sliding scale or continue checks PRN) 24hr urine Q wk, if required

Nursing Considerations-TPN
Central cannulas should be inserted and cared for using sterile technique. Routine central line changes are currently not recommended.

Nursing Considerations-TPN
Central lines should be removed when:
they are no longer medically necessary if the initial site becomes infected if the line is suspected as the source of bacteremia or clinical sepsis

Nursing considerations- TPN:

Parenteral nutrition catheters -use exclusively for parenteral nutrition. All TPN -admix only in the pharmacy using aseptic technique. [no additives on floor]. TPN & Lipid solutions to be completed within 24hrs of initiation. TPN/PPN administration tubing, with filter, -changed Q72hrs [Q24hrs when transfusing with Lipids]

Nursing considerations- TPN

Between changes of components, the IV system to be maintained as a closed system. A 0.22um bacterial retentive filter is required during administration of TPN. Change transparent dressing to insertion site once/week & PRN. Change needleless connectors [CLC2000] Qwk. Injection ports to be decontaminated with alcohol swab prior to connecting.

Nursing Considerations- TPN

All containers of parenteral fluids to be checked for visible turbidity, leaks, cracks, particulate matter, and expiry date before use.
If there is a problem- do not use.

Complications
Catheter-related sepsis
meticulous aseptic technique is essential Air embolism

Central venous thrombosis Catheter occlusion Hyperglycemia Hypoglycemia

Enteral Nutrition/Tube Feeds

Enteral Nutrition is the administration of nutrients directly into the gastrointestinal tract.
It is the preferred method for providing nutrition and should be used when the patients GI tract is functional, before considering parenteral nutrition.

Advantages of EN over TPN/PPN

Maintenance of gut structure and function Enhanced use of nutrients Safety of administration Reduced cost

Normal intestinal villus, during fed state

Contraindications of Tube Feeds/ Enteral Nutrition

minimal GI function- partially maintained severe short bowel syndrome intestinal obstruction intractable vomiting & diarrhea acute GI bleed inability to gain enteral access severe IBD severe acute Pancreatitis

Deterioration of gut integrity from gut disuse

Selection of Enteral Access device

Considerations:
status of GI tract/ diagnosis risk of aspiration estimated duration of EN

Types of Feeding Tubes:

Nasogastric tubes
[usually small bore tubes]

preferred - flexible feeding schedules weighted & non-weighted need to have an intact gag or cough reflexes and gastric emptying short-term access; no longer than 6-8 weeks

Types of Feeding Tubes:

Nasojejunal or Nasoduodenal tubes
[usually small bore tubes] decreased risk of aspiration mostly weighted unable to tolerate bolus feeds requires a feeding pump for administration

Types of Feeding Tubes:

G-Tube & J-Tube
Decreased risk of aspiration Feeding schedules are more limited Long-term access: more than 6-8 wks

Gastro & Jejunostomy Tubes

Surgically & laparoscopic placed G-tubes & J-tubes G-tubes [or J-tubes] placed under U/S Percutaneous endoscopic gastrostomy [PEG] tubes Percutaneous endoscopic jejunostomy [PEJ] tubes Foley catheters

PEJ and PEG

Gastrostomy Devices:
Low profile devices
Button Replacement Gastrostomy tubes

G-Tube & J-Tube

Insertion Site Care
After 24 hours remove initial dressing and leave open to air Cleanse site daily with normal saline or mild soap and warm water Rotate the external bumper 90 degrees Assess the site for purulent drainage, increased redness or warmth, rashes and site tenderness

Maintenance of Feeding Tube Position

Measure and mark the tube Secure the tube with tape, dry dressings Occasionally sutured in place Vomiting, leakage or pain may be signs of device malposition

Standard Starter Regimen:

Standard Continuous Feeding Schedule via a pump will be initiated full strength at 10cc/hr x 8 hrs. Increase rate by 10 ccs q8h to a final rate of ____cc/h.

Tube Feeding Administration Methods

Continuous [via infusion pump or gravity] Intermittent [via infusion pump or gravity] Bolus intermittent [via syringe or bulb] Cyclic intermittent [via infusion pump or gravity flow]

Administering Enteral Feedings

Place patient in high Fowlers position or elevate head of bed 30 degrees Check tube placement [Xray if initiating] Advance tube feeding rate gradually Continuous feedings should be flushed with sterile water, & have residuals checked every 4-8 hrs and tube placement verified at that time

Enteral feeding cont

If formula is infusing continuously over 24 hours, the refillable delivery sets must be changed every 24 hours Formula is not to hang at room temperature for more than 6-8 hours Infusion pumps must be used for all J-tubes, and G-tubes when formula is infusing continuously over 24 hours

Checking Tube Placement:

X-ray prior to initiating feeds & when unsure of position Listening for a whooshing or gurgling sound when air is inserted is no longer considered totally reliable by itself Measuring the pH (inject 30 mls of air into the tube and aspirate GI contents with a syringe and measure the pH) Gastric pH 1-4, intestinal pH >7,and Tracheobronchial pH>7 Gastric residuals check color

Enteral Device Patency

Flush tube with 30-50 cc of sterile water (only use water) every 4-6 hours, to maintain patency Flushing is also required before & after: infusion of any med via feeding tube; each interruption in feeding; and each period in intermittent feeding Use a pump for continuous feeds Prevent bacteria contamination in formula

Enteral Tube Rupture

To prevent tube rupture, use a pressure no greater than 40 psi Syringes smaller than 60mL for Gtubes or J-tubes should not be used

Clogged Tubes
Best approach: Prevent clogs from occurring by flushing before and after meds, and q4-6h. If a clog occurs: attach 60 ml syringe to the end of the enteral device and attempt to aspirate for G-tube only If unsuccessful, fill the syringe with 5-10 mls of warm water and attach it to the end of the enteral device and instill over 1 minute Clamp tube for 5-15 minutes

Clogged Tubes:
If no success, may try:
Pancreatic enzymes
Mix with sodium bicarb

Assessing Tolerance to Feeds

Assess bowel function- check bowel sounds Assess frequency and consistency of bowel movements Observe patient for nausea,vomiting, or symptoms of aspiration Measure abdominal girth Assess for bloating and distention Check gastric residuals q4-6hrs or before each intermittent feeding

Mineral water Other Pharmacy preparations Pop

Risk of bacterial contamination Contributes to future clogs

Blue Dye for Aspiration Monitoring

Warning from Health Canada:
Do not use blue food coloring to check for aspiration or leakage of enteral feeds.

Residuals??
Physician should specify how much residual should be present in order to hold feeds Check residual with a 60 mL Try insufflating 20 mls of air into tube initially Return residual volume to stomach- contains nutrition, fluids and electrolytes If residual exceeds limit, hold feeds & recheck in 1 hour. Evaluate rate. Flush tube with 10-30mls of water following residual checks

Residuals- High Risk Patients

High risk patients include:
those with absent or diminished cough or gag refluxes decreased level of consciousness anatomical abnormalities along the placement pathway (i.e., tracheostomy, endotracheal intubation, cardiomegaly) significant debilitation or difficult tube placement.
(Bohnker, Artman, Hoskins, 1987)

Residuals
General Rule for maximum residuals: 2 times the hourly rate for continuous feeds One half of the volume of the intermittent feeding for intermittent feeds with an upper limit of 200 mls

Formulation
Supplements:
Ensure, Osmolite, Isocal, Jevity, Peptamen, Promote 1 calorie per cc Higher caloric formulas available at 1.5-2 cal per cc Special formulas available for:
Low volume High fibre High protein High calorie Low sugar/CHO High nitrogen Nutritionally complete formula with vitamins & minerals for renal failure patients

Medication Administration
Whenever possible, medications should be taken p.o. or, if available by IV route. Use liquid medication whenever possible Dont mix meds with feeding formula Dont use enteric coated or time-release tablets or capsules Dont use excess force Crush tablet finely and dissolve it in at least 30 mls warm water

Medication Administration
Do not mix meds together & give at once Flush the tube with at least 10 mls of warm water between doses Flush the tube with 30 mls of water using a 60 ml syringe before and after administration of medications Consider tube placement in relation to the drugs optimal absorption Before administering a thick liquid medication, dilute it with 60 mls of water

Possible Drug Interactions:

Dilantin- impaired absorption Warfarin- resistance related to Vit K Antibiotics- Cipro binds with the formula Sinemet- high protein feeds may impair onset Enteric coated drugs Sustained/extended release drugs

Adverse Effects with Meds

There are more likely to be problems with absorption when the tube is placed beyond the stomach such as with percutaneous endoscopic jejunostomy (PEJ) tubes.
Drugs that may be affected by this include digoxin, cephalexin, ketoconazole, phenytoin and other anticonvulsants.

Examples of drug interactions with enteral feeds

Medication-Type of Interaction Ciprofloxacin- Absorption decreased by a possible 25 per cent due to interaction with feeds. Hydralazine- Decreased absorption and concentration Sulcrate- Binds to the protein in the feed Warfarin- May interact with vitamin K content of feed Suggestion Stop enteral feed for one hour before and two hours after dose or administer higher doses or use IV treatment in severe infections. Monitor changes in blood pressure Use alternatives, eg, ranitidine b/c enteral feed has to be stopped for a total of 12 hr/per day Monitor INR closely

The sorbitol content and osmolality of liquids can be associated with GI adverse effects such as sudden-onset osmotic diarrhea, bloating, stomach cramps, and delayed gastric emptying because of the regulatory role of osmoreceptors in the duodenum.

Nursing Considerations
Assess patients tolerance to therapy:
Ask patient how they are doing [any cramping, diarrhea, or constipation] Examine the abdomen [assess for distention] Auscultate for bowel sounds Evaluate stool pattern Q shift Check residuals Q6-8 hrs

Nursing Considerations
Laboratory tests are ordered on a regular basis to assess tolerance to feeds Assess insertion site for drainage, pressure sores, bleeding, redness, & tenderness Assess patency & position of tube Q shift

Nursing Considerations
Observe for signs of aspiration:
Watch for increased SOB, cough, & phlegm [note color], difficulty swallowing [assess gag reflex], and increased temp., heart rate, and respiratory rate Ensure head of bed elevated

Possible Complications
GI
Gastroesophageal reflux- elevate head of bed Nausea and vomiting- will occur if tube not placed properly or if gastric retention, residuals Aspiration- elevated head of bed Diarrhea- usually caused by antibiotics or bacterial contamination of feeds Constipation- should not happen with proper hydration and formula choice - may need to be supplemented

Possible Complications
Possible metabolic complications (if enteral product is not appropriate choice for pts diagnosis):
Dehydration- supplement as needed Elevated serum electrolytes, decreased serum electrolytes, elevated serum urea, creatinine, triglycerides Hyperglycemia-due to high carbohydrate load Vitamin deficiency- occurs when feeding provides less than 1500 calories daily

Possible Complications
Mechanical
Tube occlusion Tube displacement Irritation or erosion Hypergranulation and discharge at site

Thank You

Questions???

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