Nutritional Support and IV Therapy Chapter 20 Nutritional Support and IV Therapy All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Nutritional Support and IV Therapy Reasons for nutritional support Many persons cannot eat or drink because of illness, surgery, or injury. Chewing or swallowing problems Refusal to eat or drink Inability to eat enough to meet nutritional needs Food cannot pass from the mouth into the stomach or small intestines. Nutritional support or intravenous (IV) therapy Ordered by the doctor to meet food and fluid needs Poor nutrition results when residents can’t ingest enough food or fluid. Aspiration is a risk. Aspiration is breathing fluid, food, vomitus or an object into the lungs. Common causes are cancer, especially cancers of the head, neck, and esophagus; trauma to the face, mouth, head, or neck; coma; dysphagia; dementia; eating disorders; nervous system disorders (see Chapter 34); prolonged vomiting; major trauma or surgery; acquired immunodeficiency disorder; and illnesses and disorders affecting eating and nutrition. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Enteral Nutrition Enteral nutrition is giving nutrients into the gastro-intestinal tract through a feeding tube. Naso-gastric (NG) tube Naso-enteral tube Nasoduodenal tube Nasojejunal tube Gastrostomy tube (stomach tube) Jejunostomy tube Percutaneous endoscopic gastrostomy (PEG) tube Gavage is the process of giving a tube feeding. Tube feedings replace or supplement normal nutrition. NG (see Fig. 20-1 on p. 341) and naso-enteral tubes (see Fig. 20-2 on p. 341) are used for short-term nutritional support—usually less than 6 weeks. Gastrostomy (see Fig. 20-3 on p. 341), jejunostomy (Fig. 20-4 on p. 341), and PEG tubes (Fig. 20-5 on p. 342) are used for long-term nutritional support—usually longer than 6 weeks. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

Formulas The doctor orders: The type of formula The amount to give When to give tube feedings A nurse gives formula through the feeding tube. Formula is given at room temperature. Tube feedings are given: At certain times (scheduled feedings, intermittent feedings) Over a 24-hour period (continuous feedings) A feeding pump is used. Most formulas contain protein, carbohydrates, fat, vitamins, and minerals. Cold fluids can cause cramping. Opened formula can remain at room temperature for about 8 hours. Microbes can grow in warm formula. Review Teamwork and Time Management: Formulas on p. 342 in the textbook. Intermittent means to start, stop, and then start again. In scheduled feedings, usually 8 to 12 ounces (oz) (40 to 360 milliliters [mL]) is given over about 30 minutes. With continuous feedings, formula drips into the feeding tube at a certain rate per minute. A pump is used. The person receives a certain amount every hour. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Report Immediately Report the following observations at once: Nausea Discomfort during the feeding Vomiting Distended 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 Diarrhea, constipation, delayed stomach emptying, and aspiration are risks. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

Preventing Aspiration Aspiration is a major risk from tube feedings. It can cause pneumonia and death. Aspiration can occur: During insertion If the tube moves out of place From regurgitation To assist the nurse in preventing 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 is breathing fluid, food, vomitus, or an object into the lungs. 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. You never check feeding tube placement. Regurgitation is the backward flow of stomach contents into the mouth. Delayed stomach emptying and over-feeding are common causes. Persons with NG or gastrostomy tubes are at great risk for regurgitation. Digestion slows with aging. Stomach emptying also slows. Older persons are at risk for regurgitation and aspiration. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

Comfort Measures Persons with feeding tubes usually are NPO (nothing by mouth). 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 The following measures are common: Clean the nose and nostrils every 4 to 8 hours. Secure the tube to the nose. Secure the tube to the person’s garment at the shoulder area. Persons with feeding tubes usually are not allowed to eat or drink (NPO—nothing by mouth). These measures are common: oral hygiene every 2 hours while the person is awake, lubricant for the lips every 2 hours while the person is awake, mouth rinses every 2 hours while the person is awake. Secure the tube to the nose (Fig. 20-8 on p. 343). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

Tube Feedings You assist the nurse with tube feedings. In some states and centers, nursing assistants give tube feedings and remove NG tubes. You are never responsible for inserting feeding tubes or checking their placement. Review Delegation Guidelines: Giving Tube Feedings on p. 344. Review Promoting Safety and Comfort: Giving Tube Feedings on p. 344. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Parenteral Nutrition (Total Parenteral Nutrition [TPN], Hyperalimentation) Parenteral nutrition is giving nutrients through a catheter inserted into a vein. This method is used when: The person cannot receive oral feedings or enteral feedings. Oral or enteral feedings are not enough to meet the person’s needs. TPN risks include infection, fluid imbalances, and blood sugar imbalances. In parenteral nutrition, a nutrient solution is given directly into the bloodstream through a catheter into a vein (see Fig. 20-9, p. 344). Nutrients do not enter the GI tract. Para means beyond and enteral relates to the bowel. 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; and prolonged anorexia (loss of appetite). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Observations to Report Report the following signs and symptoms to the nurse at once: Fever, chills, and other signs and symptoms of infection Signs and symptoms of sugar imbalances Chest pain Difficulty breathing, shortness of breath, or cough Nausea, vomiting, or diarrhea Thirst Rapid heart rate or an irregular heartbeat Weakness or fatigue Sweating Pallor or trembling Confusion or changes in behavior TPN risks include infection (see Chapter 13), fluid imbalances, and blood sugar imbalances (see Diabetes Chapter 36). All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

Caring for the Person with TPN Assisting with TPN The nurse is responsible for all aspects of TPN. You assist the nurse by carefully observing the person. You assist the nurse with the person’s basic needs and activities of daily living. Persons receiving TPN may be NPO, meaning they are to receive nothing by mouth. Provide frequent oral hygiene, lubricant to the lips, and mouth rinses as the nurse and care plan direct. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

Intravenous Therapy (IV Therapy, IV Infusion) 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. Peripheral and central venous sites are used. Peripheral sites are away from the center of the body. Central sites are close to the heart. Intravenous (IV) therapy is giving fluids through a needle or catheter inserted into a vein (see Fig. 20-10, p. 345). Fluid flows directly into the bloodstream. RNs start and maintain the infusion according to the doctor’s orders. RNs also give IV drugs and administer blood. State laws vary about the role of LPNs/LVNs and nursing assistants in IV therapy. For adults, the back of the hand and inner forearm are useful peripheral sites (see Fig. 20-11, p. 346). The subclavian vein and the internal jugular vein are central venous sites (see Fig. 20-12, p. 346). Central venous sites are used for parenteral nutrition, to give large amounts of fluid, for long-term IV therapy, and to give drugs that irritate peripheral veins. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

Equipment IV equipment The solution container is a plastic 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. The solution container, a plastic bag, is called the IV bag. A catheter or needle is inserted into the vein. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13

Flow Rate Flow rate is number of drops per minute The RN sets the clamp for the flow rate. Or an electronic pump is used to control the flow rate. An alarm sounds if something is wrong. Tell the nurse at once if you hear an alarm. Never change the position of the clamp or adjust any controls on IV pumps. You can check the flow rate by counting drops in 1 minute or comparing the fluid line with the time line on the time tape. Tell the RN at once if: No fluid is dripping. The rate is too fast. The rate is too slow. The doctor orders the amount of fluid to give (infuse) and the amount of time to give it in. With this information, the RN figures the flow rate. The abbreviation gtt means drops (from the Latin word guttae, meaning “drops”). To check the flow rate, count the number of drops in 1 minute. The time tape shows how much fluid to give over a period of time (Fig. 20-16 on p. 347). For example, the doctor orders 1000 mL of fluid over 8 hours. The RN marks the tape in 8 1-hour intervals. To check if the infusion is on time, compare the fluid line with the time line on the tape. If the fluid line is above or below the time line, the flow rate is too slow or too fast. Review Promoting Safety and Comfort: Flow Rate on p. 346. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14

Assisting with IV Therapy Your state and center 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. Review the safety measures for IV therapy in Box 20-1 on p. 348. Report at once any of the signs and symptoms of IV therapy complications listed in Box 20-2 on p. 348. Review Teamwork and Time Management: Assisting with IV Therapy on p. 347. Review Delegation Guidelines: Assisting with IV Therapy on p. 349. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15

Quality of Life Persons needing nutritional support or IV therapy are often very ill. At all times, you must give quality care and protect the person’s rights. Sometimes decisions are made to stop nutritional support or IV therapy. Talk to the nurse if you have problems with the decision. Care needs for persons needing nutritional support or IV therapy may be great and take a lot of time. Do not take short cuts or omit care. Doing so is unethical. It could also cause great harm. The person (or the family after talking to the doctor) may make the decision to stop nutritional support or IV therapy. You may agree or disagree with such choices. The choice may or may not be within your religious or cultural beliefs and values. The person’s or family’s wishes and doctor’s orders must be followed. The person must receive quality care. If you have problems with the decision, the nurse may need to change your assignment. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16