Nutritional Support and IV Therapy Chapter 25 Nutritional Support and IV Therapy Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Doctor’s Order The doctor may order nutritional support or IV therapy to meet food and fluid needs for persons who: Cannot eat or drink because of illness, surgery, or injury Have problems eating or refuse to eat or drink Cannot eat enough to meet their nutritional needs Aspiration is a risk for persons with chewing or swallowing problems. Aspiration is breathing fluid, food, vomitus, or an object into the lungs. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Enteral Nutrition Enteral nutrition is giving nutrients into the gastro-intestinal (GI) tract through a feeding tube. Gavage is the process of giving a tube feeding. Tube feedings replace or supplement normal nutrition. Poor nutrition results when a person cannot or will not ingest, chew, or swallow food, or when food cannot pass from the mouth into the esophagus and into the stomach or small intestine. Common causes are cancer; trauma to the face, mouth, head, or neck; coma; dysphagia; dementia; eating disorders; nervous system disorders; prolonged vomiting; major trauma or surgery; AIDS; and illnesses and disorders that affect eating and nutrition. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Enteral Nutrition (cont’d) Common feeding tubes Naso-gastric (NG) tube—Feeding tube is inserted through the nose into the stomach. Naso-enteral tube—Feeding tube is inserted through the nose into the small bowel. Gastrostomy tube (stomach tube)—Doctor surgically creates an opening in the stomach and a tube is inserted. Jejunostomy tube—Feeding tube is inserted into a surgically created opening in the jejunum of the small intestine. Percutaneous endoscopic gastrostomy (PEG) tube—Doctor inserts the feeding tube with an endoscope. An endoscope is a lighted instrument used to see inside a body cavity or organ. NG and naso-enteral tubes are used for short-term support—usually less than 6 weeks. Gastrostomy, jejunostomy, and PEG tubes are used for long-term nutritional support—usually longer than 6 weeks. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Enteral Nutrition (cont’d) Formulas The doctor orders the type of formula, the amount to give, and when to give tube feedings. Formula is given at room temperature. Feeding times Scheduled feedings (intermittent feedings) are given at certain times. At least 4 feedings are given each day. The nurse uses a syringe or a feeding bag. Continuous feedings are given over 24 hours. A feeding pump is used. Most formulas contain proteins, carbohydrates, fats, vitamins, and minerals. Commercial formulas are common. Cold fluids can cause cramping. Opened formula can remain at room temperature for about 8 hours. Microbes can grow in warm formula. Review the Teamwork and Time Management: Formulas Box on p. 456 in the Textbook. With scheduled feedings, the frequency, amount, and time are like a normal eating pattern. When a pump is used, an alarm sounds if something is wrong. When you hear an alarm, tell the nurse. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Enteral Nutrition (cont’d) Report the following observations at once: Nausea Discomfort during the feeding Vomiting Distended (enlarged and swollen) abdomen Coughing Complaints of indigestion or heartburn Redness, swelling, drainage, odor, or pain at the ostomy site Fever Signs and symptoms of respiratory distress Increased pulse rate Complaints of flatulence Diarrhea The person is at risk for diarrhea, constipation, delayed stomach emptying, and aspiration. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Enteral Nutrition (cont’d) Aspiration is a major risk from tube feedings. Aspiration can occur: During insertion From tube movement out of place From regurgitation To help prevent regurgitation and aspiration: Position the person in Fowler’s or semi-Fowler’s position before the feeding. Follow the care plan and the nurse’s directions. Maintain Fowler’s or semi-Fowler’s position after the feeding. Avoid the left side-lying position. Aspiration can cause pneumonia and death. During insertion, the tube can slip into the airway. An x-ray is taken after insertion to check tube placement. Coughing, sneezing, vomiting, suctioning, and poor positioning are common causes of the tube moving out of place. The RN checks tube placement before every scheduled tube feeding. With continuous feedings, the RN checks tube placement every 4 hours. You are never responsible for checking feeding tube placement. Regurgitation is the backward flow of stomach contents into the mouth. Persons with NG or gastrostomy tubes are at great risk for regurgitation. Review the Focus on Children and Older Persons: Preventing Aspiration Box on p. 457 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Enteral Nutrition (cont’d) Persons with feeding tubes usually are not allowed to eat or drink. Dry mouth, dry lips, and sore throat can cause discomfort. Feeding tubes can: Irritate and cause pressure on the nose Change the shape of the nostrils Cause pressure ulcers Assisting the nurse with tube feedings In some states and agencies, nursing assistants give tube feedings and remove NG tubes. You are never responsible for inserting feeding tubes or checking their placement. Common comfort measures every 2 hours while the person is awake include oral hygiene, lubricant for the lips, and mouth rinses. Measures for nose irritation include cleaning the nose and nostrils every 4 to 8 hours, and securing the tube to the nose and to the person’s garment at the shoulder area to prevent pulling or dangling. Review the Delegation Guidelines: Assisting With Tube Feedings Box on p. 458 in the Textbook. Review the Promoting Safety and Comfort: Assisting With Tube Feedings Box on p. 459 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Comfort Measures Common comfort measures every 2 hours while the person is awake include oral hygiene, lubricant for the lips, and mouth rinses. Measures for nose irritation include cleaning the nose and nostrils every 4 to 8 hours, and securing the tube to the nose and to the person’s garment at the shoulder area to prevent pulling or dangling. Tube feeding can only hang for 8 hours

Parenteral Nutrition Parenteral nutrition is giving nutrients through a catheter inserted into a vein. Often called total parenteral nutrition (TPN) or hyperalimentation Nutrient solution is given directly into the bloodstream; nutrients do not enter the GI tract. This method is used when: The person cannot receive oral or enteral feedings. ie gastric paresis Oral or enteral feedings are not enough to meet the person’s needs. The solution contains water, proteins, carbohydrates, vitamins, and minerals. It drips through a catheter inserted into a large vein. Common reasons for TPN include disease, injury, or surgery to the GI tract; severe trauma, infection, or burns; being NPO for more than 5 to 7 days; GI side effects from cancer treatments; prolonged coma; prolonged anorexia (loss of appetite). Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Total Parenteral Nutrition Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Parenteral Nutrition (cont’d) Report the following to the nurse at once: Fever, chills, and other signs and symptoms of infection Signs and symptoms of sugar imbalances Chest pain Difficulty breathing or shortness of breath Cough Nausea and vomiting Diarrhea Thirst Rapid heart rate or an irregular heartbeat Weakness or fatigue Sweating Pallor (pale skin) Trembling Confusion or behavior changes TPN risks include infection, fluid imbalances, and blood sugar imbalances. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Parenteral Nutrition (cont’d) Assisting with TPN The nurse is responsible for all aspects of TPN. You assist the nurse by carefully observing the person: Protecting the IV when ambulating, following Bloodborne Pathogen Standard and reporting any site issues to the nurse. You assist with the person’s basic needs and activities of daily living. The person may be NPO. Provide frequent oral hygiene, lubricant to the lips, and mouth rinses as the nurse and care plan direct. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

IV Therapy Intravenous (IV) therapy (IV infusion) is giving fluids through a needle or catheter inserted into a vein. Doctors order IV therapy to: Provide fluids when they cannot be taken by mouth. Replace minerals and vitamins lost because of illness or injury. Provide sugar for energy. Give drugs and blood. RNs are responsible for IV therapy. State laws vary about your role and that of LPNs/LVNs in IV therapy. With IV therapy, fluid flows directly into the bloodstream. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

IV Therapy (cont’d) Peripheral and central venous sites are used. Peripheral IV sites are away from the center of the body. Central IV sites are close to the heart. The subclavian vein and the internal jugular vein are central venous sites. The cephalic and basilic veins in the arm also are used. Catheters inserted into these sites are called peripherally inserted central catheters (PICCs). Central venous sites are used: For parenteral nutrition To give large amounts of fluid For long-term IV therapy To give drugs that irritate peripheral veins For adults, the back of the hand and the inner forearm provide useful peripheral IV sites. Review the Focus on Children and Older Persons: IV Sites Box on p. 460 in the Textbook. Review the Focus on Long-Term Care and Home Care: IV Sites Box on p. 460 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

IV Therapy (cont’d) Basic equipment used in IV therapy The solution container is a plastic bag. It is called the IV bag. A catheter or needle is inserted into a vein. The IV tube or infusion tubing connects the IV bag to the catheter or needle. Fluid drips from the bag into the drip chamber. The clamp is used to regulate the flow rate. The IV bag hangs from an IV pole (IV standard) or ceiling hook. Refer to Figure 25-10 on p. 460 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

IV Therapy (cont’d) Flow rate The doctor orders the amount of: Fluid to give (infuse) Time to give it in The RN figures the flow rate. The flow rate is the number of drops per minute (gtt/min) or milliliters per hour (mL/hr). The RN sets the clamp for the flow rate or an electronic pump may be used to control the flow rate. An alarm sounds if something is wrong. Tell the nurse at once if you hear an alarm. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

IV Therapy (cont’d) Never change the position of the clamp or adjust any controls on IV pumps. You can check the flow rate if a pump is not used. Count number of drops in 1 minute. Tell the RN at once if: No fluid is dripping. The rate is too fast. The rate is too slow. The MD orders specify how much fluid to give over a certain time period Review the Promoting Safety and Comfort: Flow Rate Box on p. 462 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

IV Therapy (cont’d) Your state and agency may allow you to: Change dressings at peripheral IV sites. Discontinue a peripheral IV. You are never responsible for: Starting or maintaining IV therapy Regulating the flow rate Changing IV bags Giving blood or IV drugs You help meet the safety, hygiene, and activity needs of persons with IVs. Follow the safety measures in Box 25-1 on p. 463 in the Textbook. Report at once any of the signs and symptoms listed in Box 25-1 on p. 463 in the Textbook. Review the Focus on Communication: Assisting With IV Therapy Box on p. 464 in the Textbook. Review the Teamwork and Time Management: Assisting With IV Therapy Box on p. 464 in the Textbook. Review the Delegation Guidelines: Assisting With IV Therapy Box on p. 464 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.