7/7/14

Tube Feeding Complications

Tube Feeding Complications

Nausea,Vomiting, and Bloating
■ Large residuals: Withhold or decrease feedings.
■ Medication: Review meds and consult physician.
■ Rapid infusion rate: Decrease rate.

Diarrhea
■ Too rapid administration: Reduce rate.
■ Refrigerated TF (too cold): Administer at room temp.
■ Tube migration into duodenum: Retract tube to reposition in stomach and reconfirm placement.

Constipation
■ Decreased fluid intake: Provide adequate hydration.
■ Decreased dietary fiber: Use formula with fiber.

Aspiration and gastric reflux
■ Improper tube placement: Verify placement.
■ Delayed gastric emptying: Check residuals.
■ Position of patient: Keep HOB elevated 30–45 degrees.

Occluded tube
■ Inadequate flushing: Flush more routinely.
■ Use of crushed meds: Switch to liquid meds.

Displaced tube
■ Improperly secured tube: Retape the tube.
■ Confused patient: Follow hospital protocol.
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NG Tube Feedings

■ Confirm placement before using: (1) Using 20-mL syringe, inject 20-mL bolus of air into feeding tube while auscultating abdomen. Loud gurgling indicates proper placement. DO NOT attempt this with water! (2) Use 20-mL syringe and gently aspirate gastric content. Dip litmus paper into gastric aspirate; pH of 1–3 suggests proper placement.
■ Maintenance: Flush with 30 mL of water every 4–6 hours and before and after administering tube feedings, checking for residuals, and administering medications.
■ Medication: Dilute liquid medications with 20–30 mL of water. Obtain all medications in liquid form. If liquid form is not available, check with pharmacy to see if medication can be crushed. Administer each
medication separately and flush with 5–10 mL of water between each medication. Do not mix medications with feeding formula!
■ Residuals: Check before bolus feeding, administration of medication, or every 4 hours for continuous feeding. Hold feeding if _100 mL and recheck in 1 hour. If residuals are still high after 1 hour, notify physician.

Types of Tube Feedings
■ Initial tube feedings: Advance as tolerated by 10–25 mL/hour every 8–12
hours until goal rate is reached.
■ Intermittent feedings: Infusions of 200–400 mL of enteral formulas several
times per day infused over a 30-minute period.
■ Continuous feedings: Feedings initiated over 24 hours with the use of an
infusion pump.

Checking Residuals
■ Using 60-mL syringe, withdraw from gastric feeding tube any residual formula that may remain in stomach.
■ Volume of this formula is noted, and if it is greater than predetermined amount, stomach is not emptying properly, and next feeding dose is withheld.
■ This process can indicate gastroparesis and intolerance to advancement to higher volume of formula.
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NG Tube: Care and Removal

NG Tube: Care and Removal

Patient Care
■ Reassess placement of tube before administering bolus feedings, fluids, or meds and at every shift for continuous feedings.
■ Flush tube with 30 mL of water after each feeding and after each administration of medication.
■ Assess for skin irritation or breakdown. Retape daily and at alternate sites to avoid constant pressure on one area of the nose. Gently wash around
nose with soap and water and dry before replacing tape. Provide nasal hygiene daily and p.r.n.
■ Provide good oral hygiene every 2 hours and p.r.n. (mouth wash, water, toothettes → clean tongue, teeth, gums, cheeks, and mucous membranes). If Pt is performing oral hygiene, remind him or her not to swallow any water.

Removal
■ Explain procedure to Pt. Observe standard precautions.
■ Remove tape from nose and face.
■ Clamp or plug tube (prevents aspiration), instruct Pt to hold breath, and remove tube in one gentle, but swift motion.
■ Assess for signs of aspiration.
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NG (Nasogastric) Tube: Insertion

■ Explain procedure to Pt and offer reassurance.
■ Auscultate abdomen for positive bowel sounds if NG tube is to be used for administration of feedings or medication.
■ Position Pt upright in high-Fowler’s position. Instruct Pt to keep chin-tochest posture during insertion. This helps to prevent accidental insertion into trachea.
■ Measure tube from tip of nose to earlobe, then down to the xiphoid. Mark this point on tube with tape.
■ Lubricate tube by applying water-soluble lubricant to tube. Never use petroleum-based jelly, which degrades PVC tubing.
■ Insert tube through nostril until you reach previously marked point on tube. Instruct Pt to take small sips of water during insertion to help facilitate passing of tube.
■ Secure tube to Pt’s nose using tape. Be careful not to block nostril. Tape tube 12–18 inches below insertion line and then pin tape to Pt’s gown. Allow slack for movement.
■ Position HOB at 30–45 degrees to minimize risk of aspiration.
■ Confirm proper location of NG tube:
■ Pull back on plunger* of a 20-mL syringe to aspirate stomach contents. Typically, gastric aspirates are cloudy and green, or tan, off-white, bloody, or brown. Gastric aspirate can look like respiratory secretions,
so it is best also to check pH.
■ Dip litmus paper into gastric aspirate. A reading of a pH of 1–3 suggests placement in stomach.
■ An alternative, but less reliable, method is to inject 20 mL of air into tube while auscultating the abdomen. Hearing loud gurgle of air suggests placement in stomach. If no bubbling is heard, remove tube and reattempt. Withdraw tube immediately if Pt becomes cyanotic or develops breathing problems.
■ An inability to speak also suggests intubation of trachea instead of stomach.
■ *Note: small-bore NI (nasointestinal) tubes (i.e., Dobhoff) may collapse under pressure, and initial confirmation of placement is obtained by xray.
■ Assemble equipment (wall suction, feeding pump, etc.) per manufacturer guidelines.
■ Document type and size of NG tube, which nostril, and how Pt tolerated procedure. Document how tube placement was confirmed and whether tubing was left clamped or attached to feeding pump or suction.
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2/24/14

Total Parentral Nutrition

Parentral nutrition is a method where by nutrients may be introduced into the system via the enteral route. It is also referee to as intravenous hyperalimenation (IVH). By passing the normal gastro intestinal system, this route provides a nitrogen source for those unable to ingest protein, carbohydrates (adequate caloric), or fats. A balanced blend of nutrients, including vitamins and minerals, can be administered peripherally, using isotonic concentrations of glucose, crystalline aminoacids, and fats; or because the solution may be irritating to the veins, nutrients can be administered through a central, high-flow vein. Hypertonic glucose, along with crystalline aminoacids, fats, electrolytes, vitamins and trace elements is given through central vein access.

The technique requires especial handling and management of the client and the most expensive method of feeding.

It should be used only if the intestines do not work adequately, if the client has an obstruction or has fistula, if the bowel rest is required.

Implantable vascular access devices are placed under the skin in a subcutaneous pocket and a surgically tunneled silicone catheter is place in the cephalic or external jugular vein and threaded to the superior vana cava.



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Guideline for healthy diet

Guide Line
Rationale
Eat a variety of foods
- No single food supplies all 40-plus essential nutrients in amounts needed variety also helps reduce the risk of nutrient toxicity and
accidental contamination
Balance the food you eat with physical activity – maintain or improve your weight
- Excess weight increases the risk of numerous chronic diseases. Such as hypertension, heart disease, and diabetes
Choose a diet with plenty of gain products, vegetables, and fruits
- Plant foods provide fiber, complex
carbohydrates, vitamins, minerals, and other substances important for good health
Choose a diet low in fat, saturated fat, and
cholesterol
- High fat diets increase the risk of obesity, heart diseases, and certain types of cancer
Choose a diet moderate in sugars
- Foods high in added sugar are “empty calories”. Both sugar and starches promote tooth decay
Choose a diet that is moderate in salt and
sodium
- A high salt intake is associate with higher blood pressure


Therapeutic Nutrition
Therapeutic nutrition is a modification of nutritional needs based on the disease condition or the excess or deficit of a nutrition status. Combination diets, which include alterations in minerals, vitamins, proteins, carbohydrates, fats as well as fluid and texture, are prescribed in therapeutic nutrition.

Gastrostomy/Jejunostomy Feedings
A gastrostomy feeding is the installation of liquid nourishment through a tube that enters a surgical opening (called a gastrostomy) through the abdominal wall in to the stomach.

A jejunostomy feeding is the installation of liquid nourishment through a tube that enters a surgical opening (a jejunostomy) through the abdominal wall in to the jejunum.

These feedings are usually temporary measures. When there is an obstruction the esophagus, they may be come permanent, for example, after removal of the esophagus.
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Healthy Diet

A healthy diet is one that provides an adequate amount of each essential nutrient needed to support growth and development, perform physical activity, and maintain health. In addition to meeting physiologic requirements, diet also used to satisfy a variety of personal, social, and cultural needs. These factors must be
considered in diet planning. The diets of all individuals must consist of foods that are easily attainable and affordable. People can use an infinite variety and combination of foods to form a healthy diet. The current philosophy is that no good foods or bad foods exist, and that all foods can be enjoyed in moderation.

Dietary Guidelines
The purpose of dietary guidelines is to provide a healthy public with practical and positive suggestions for choosing a diet that meets nutritional requirements, support activity, and reduces the risk of malnutrition and chronic disease. These guidelines are not intended as a diet prescription for specific individuals, but serve as a starting point from which people can plan healthy diets.
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Nutrition

Nutrition is the study of nutrients and how the body utilizes the nutrients in food. Nutrition has a great impact on human well-being,behavior, and the environment.

Nutrients are substances needed for growth, maintenance, and repair of the body. The body can make some nutrients if adequate amount of necessary precursors (building blocks) are available.

Essential nutrients are those that a person must obtain through food because the body can not make them in sufficient quantities to meet its needs. The six classes of nutrients are carbohydrates, fat, protein, water, minerals, and vitamins. Carbohydrate, fat and protein provide energy and are called macronutrients. Vitamins and
minerals regulate body process and are called micronutrients. Water is necessary for virtually every body function.

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2/9/14

Providing first aid to a client who is choking

In clients who are choking it is essential to remove the obstruction and clear the airway to prevent asphyxia.

Adult:
If blockage of the airway is only partial, the client will usually be able to clear it by coughing so should be instructed to do so; but if obstruction is complete, urgent intervention is required to prevent asphyxia. Therefore if the client is conscious and breathing, despite evidence of obstruction:

Encourage them to continue coughing, but do nothing else.
If obstruction is complete, or the client shows signs of exhaustion or becomes cyanosed but is still conscious, carry out back blows as explained below.

Procedure
Rationale
Remove any obvious debris or
loose teeth from the mouth
To clear airway of observable blockages and
prevent inhalation of debris/teeth
Stand to the side and slightly behind client, support their chest with one hand and lean them well forward
To ensure that when obstructing object is
dislodged it comes out of the mouth rather than
going further down the airway
Give up to five sharp blows between the scapulae (shoulder blades) with the heel of your other hand; each blow should be aimed at relieving the obstruction, so all
five need not necessarily be given
To dislodge the obstruction
If back blows fail, carry out abdominal thrusts:
Stand behind the client and put your arms around the upper part of the abdomen
Correct position to administer abdominal thrusts
Make sure the client is bending well
forwards
To ensure that when the obstructing object is
dislodged it comes out of the mouth rather than
goes further down the airway
Clench your fist and place it between the umbilicus (navel) and xiphisternum (bottom tip of the sternum) and grasp it with your other hand
To ensure correct hand position
Pull sharply inwards and upwards
To dislodge the obstructing object
If the obstruction is not relieved, recheck the mouth for any
obstruction that can be reached with a finger, and continue
alternating five back blows with five abdominal thrusts
To dislodge the obstructing object
If the client at any time becomes unconscious, carry out the following sequence of life support
(see Chapter 1):
Open the client’s airway and remove any visible obstruction
from the mouth.
To facilitate respirations
Check for breathing by looking, listening and feeling
To establish whether respiration has ceased.
If not breathing, attempt to give two rescue breaths.
Expelled air will enter client’s lung fields, providing
some oxygen
If effective breaths can be achieved within five attempts check for signs of a circulation and start chest compressions as given in Chapter 4 and/or rescue breaths as appropriate
See Chapter 4
If effective breaths cannot be achieved within five attempts:
Start chest compressions immediately and do not check for signs of circulation.
To relieve obstruction and continue resuscitation
After 15 compressions check the mouth for any obstruction then attempt further rescue breaths.
Obstruction may have been dislodged by chest
compressions
Continue to give cycles of 15 compressions
followed by attempts at rescue breathing
To sustain circulation of blood during cardiac
arrest – see Chapter 4
If at any time effective breaths can
be achieved:
• Check for signs of a circulation
• Continue chest compressions
and/or rescue breaths as
appropriate
If obstruction is dislodged quickly a spontaneous
circulation may return



Child and infant

If a child is breathing spontaneously, his/her own efforts to clear the obstruction should be encouraged. Intervention is necessary only if these attempts are clearly ineffective and breathing is inadequate.

• Do not perform blind finger sweeps of the mouth or upper airway as these may further impact a foreign body or cause soft tissue damage.
• Use measures intended to create a sharp increase in pressure within the chest cavity (an artificial cough), such as those procedures outlined below.

Procedure
Rationale
Perform up to five back blows:
• Hold the child in a prone position and try to position
the head lower than the shoulders with the airway
• Deliver up to five smart blows to the middle of the
back between the shoulder blades
• If this fails to dislodge the foreign body proceed to
chest thrusts
To dislodge the obstruction
by creating a sharp increase
in pressure within the chest
cavity – an artificial cough
Perform up to five chest thrusts:
• Turn the child into a supine position, again with the
head lower than the shoulders and the airway in an
open position
• Give up to five chest thrusts to the sternum:
The technique for chest thrusts is similar to that for
chest compressions (see Chapter 4)
Chest thrusts should be sharper and more vigorous
than compressions and be carried out at a rate of
about 20 per minute
As above
Check mouth:
• After five back blows and five chest thrusts check the
mouth
• Carefully remove any visible foreign bodies
Foreign object may have
been dislodged
Open airway:
• Reposition the airway by the head tilt and chin lift
manoeuvre
• Reassess breathing (refer to Chapter 1)
To facilitate respiration or
to establish whether
spontaneous respirations
have ceased
If the child is breathing:
• Turn the child into the recovery position
• Check for continued breathing
To maintain airway and
monitor respirations
If the child is not breathing:
• Attempt up to five rescue breaths (refer to Chapter 1)
to achieve two effective breaths, each of which make
the chest rise and fall. The child may be apnoeic or the
airway partially cleared; in either case the rescuer may
be able to achieve effective ventilation at this stage
• If the airway is still obstructed repeat the sequence as
follows:

For a child:
• Repeat the cycle previously outlined but substitute five
abdominal thrusts for five chest thrusts:
Use the upright position if the child is conscious;
kneel behind a small child
Unconscious children should be laid supine and the
heel of one hand placed in the middle of the upper
abdomen
• Alternate chest thrusts and abdominal thrusts in subsequent
cycles
• Repeat the cycles until the airway is cleared or the
infant breathes spontaneously

For an infant:
• Abdominal thrusts are not recommended in infants as
they may rupture the abdominal viscera
• Perform cycles of five back blows and five chest
thrusts only
Repeat the cycles until the airway is cleared or the infant
breathes spontaneously
To dislodge obstruction

If the infant or child stops breathing follow the BLS algorithm as outlined in Chapter 4.

It is important to stay with the client following any successful first aid measures, to provide reassurance and to address any further concerns or worries they may have; always ensure that the client is safe from further danger before leaving.
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Feeding dependent clients and clients with potential swallowing difficulties

Due to physical impairment, swallowing difficulties or generalized weakness some clients may be unable to feed themselves without assistance. In addition, some clients with severe dementia can also require assistance as they may not recognize food or cutlery or remember how to feed themselves. Having to be fed can threaten the client’s dignity; therefore the health care professional should try to minimize any negative aspects that may contribute to these feelings. Therefore in addition to the guidelines outlined above, the procedure outlined below may also need to be considered. The aim of feeding dependent clients is to ensure that they receive the optimum amount of food and fluid whilst maintaining their dignity and safety.
Procedure
Rationale
Wash hands following correct
procedure and put on appropriate
coloured apron, and also assist the
client to wash their hands
Infection control
Ensure that the client is in a
comfortable position, preferably
upright and sitting out of bed in a
comfortable chair drawn up to a
table of comfortable height
Sitting the client as upright as possible allows
the first third of the oesophagus to work, generating
a wave of peristalsis that takes food and
fluid into the stomach and also lessens the risk
of food passing into the respiratory tract
If clients are unable to get out of
bed ensure they are sat upright if
condition allows; pillows should be
arranged so that they can lean forward
As above
Put adjustable chairs into the
upright position for meals and
drinks and do not put back to
recline position for at least
15 minutes afterwards
To prevent reflux of gastric contents
Ensure that the client can close
their lips
A lip-seal needs to be maintained to trigger a
swallow
Sit down at the same level to feed
the client
Demonstrates a relaxed approach and that you
can spend time with the client
Protect the client’s clothing with a
napkin
Maintains dignity
Ask the client in what order they
would like the food
Client’s likes/dislikes are met
Talk to the client but avoid asking
questions during mealtimes
To avoid distracting the client during mealtimes
Allow time for the client to chew
and swallow the food and drink
before offering the next mouthful
To prevent client from feeling hurried as this
could result in discouraging the client from
eating
Adjust the amount of food and
drink offered to suit client – a
teaspoon per mouthful is plenty,
and is best placed in the stronger
side of the mouth
As above. Lessens risk of aspiration and choking
Allow two swallows per mouthful
Ensures mouth is empty
After every few mouthfuls ask the
client to cough and to do so again
at the end of the meal
To check and clear the airway
When giving a drink, tip the cup
gently or use a feeder cup
Ensures flow of fluid is controlled and regulated.
Lessens risk of aspiration and choking
With a napkin remove any dribbles
of food or drink from the client’s
chin
To maintain client’s dignity
During feeding listen to the client’s
voice by asking them to say ‘Ah’
after every few mouthfuls and if
the client’s voice sounds ‘wet’ or
‘gurgly’ stop feeding and call for
qualified assistance
A wet or gurgly-sounding voice is a sign of aspiration
into the respiratory tract
After the meal is completed check
the mouth for retained food and
remove it with a swab or toothbrush
To prevent aspiration and choking on retained
food particles
Observe for any signs of choking,
for example coughing or poor
colour, and stop feeding
immediately if this is suspected
(refer to section below on choking)
To minimize harm

Further points
When feeding dependent clients and clients with potential swallowing problems consider the following:
• If a hot drink is delivered too early, put a lid on it and check it again later.
• A straw may be used to assist a client to drink. However, some clients may not be able to use a straw if their orbicularis oris muscle (the muscle around the mouth) is weak, as in some stroke patients, because it makes their suction power lower; straws with valves or a feeder cup may help.

• Some clients who cannot communicate their needs may go red in the face after meals, which may indicate that they need to defecate as a result of the gastrocolic reflex (putting food in at the top causes the system to shunt into action).

• All clients with problems swallowing must be referred to a speech and
language therapist.

• The easiest consistency to eat is a smooth texture. Soft solids such as ice cream, yoghurt, custard and mashed potato are acceptable. Normal solids and thickened liquids are more difficult. These include thick milkshakes, yoghurt drinks and thickened soups.

• Note: It is important that the dietician in consultation with the speech and language therapist prescribes the appropriate diet after assessing the client, and you should therefore seek their guidance on the use of thickening powders etc. before you use them.

• Food types to be avoided by the client with eating or swallowing difficulties are those which are stringy, crumbly, tough, or of mixed textures (solids and fluids) or such things as chips, peas and sweetcorn.
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