1. NUTRITION
Alternative Methods

2. NUTRITION What is it? Metabolic Requirements Caloric Requirements
Energy Nutrients
Regulatory Nutrients
Nutrition is the science of how food nourishes the human body
Metabolic:- at rest requirements
Caloric requirements: how much to maintain body weight
everyone is different based on weight, activity level, etc
Energy- Carbohydrates, Protein, Fats
Regulation- Vitamins and Minerals, Water

3. FACTORS AFFECTING NUTRITION
Physiologic and Physical Factors
Age and Development
Gender
Health Status
Substance Abuse
Medications
Supplements
Age- needs change in relation to growth patterns need for nutrients remains the same
Gender-men have larger muscle mess
Health status- alterations from illness and trauma
Substance abuse- alcohol alters body’s nutrients
Medications- can alter absorption of nutrients
Supplements- excess of one can cause deficiency in another because of the way the body absorbs by preference

4. FACTORS AFFECTING NUTRITION
Sociocultural and Psychosocial Factors
Economic Factors
Religion
Meaning of Food
Culture
Economic Factors- budget for nutritional foods
Religion- many do not eat certain foods or preparations ASK client preferences do not generalize
Meaning of Food- many use food for stress management/ psychosocial component
Culture- affects variability of foods, client may use homeopathic or herbal supplements ASK client specific questions

5. The Nursing Process: NUTRITION
NANDA Diagnosis-
Outcome Planning-
Evaluation-
Talk through some diagnosis and interventions
Imbalanced nutrition- more and less
Risk for- (possible short term, fever, infection, etc)
Wellness DX- Readiness for enhanced nutrition

6. The Nursing Process: NUTRITION
Dietary Intake
24 Hour Diet Recall
Food Diaries/Calorie Counts
Anthropometrics
Measurements to determine body dimensions
Barriers to Nutrition
Dysphagia: difficulty swallowing
Laboratory Values
Recall/calorie counts: assessing for too much, too little (imbalances)
Measurements: BMI, waist circumference
Lab values: H&H=anemia, albumin=possible malnutrition

7. The Nursing Process: NUTRITION
Diet progression
Assessing tolerance of diets, advancing diet
Stimulating appetite
Assistance with meals
Therapeutic diet consideration
Vegetarian, renal, cardiac, diabetic
Nothing By Mouth (NPO)
Providing comfort, alternate methods of nutrition
Stimulating: removing barriers like pain and nausea
Involve the client as much as possible when assisting with feeding
Providing Comfort: good oral hygiene, ice chips if allowed

8. Alternate Feeding: ENTERAL NUTRITION
Oral nutrition is still the preferred and most effective method of nutrition
For patients requiring more nutrition or NPO for > 2 days
Feeding Tubes
Short-Term: Nasogastric tube, Nasointestinal tube
Long-Term: Percutaneous Endoscopic Gastrostomy (PEG) tube, Jejunostomy tube (J-Tube), Low Profile Gastrostomy Device (LPGD)

9. Ethics in Nursing: Tube Feedings
Role of the nurse:
The decision to place, maintain, and/or discontinue feeding tubes can be a source of much turmoil in the lives of patients and their families. There are many emotional, physical, psychological, and cultural aspects to the institution, maintenance, and withdrawal of nutrition. Nurses can be a source of great support and information to aid patients and their families in making nutrition-related health care decisions.

10. SHORT-TERM FEEDING TUBES
Nasogastric
Inserted through the nose into the stomach
Tubing is firm and large in diameter
Used for tube feedings and medication administration
Must have a functioning GI tract
Patient Considerations: Not a good candidate if…
Poor gag reflex
Gastric stasis
Reflux
Have a higher risk of aspiration
Nasal injuries
Can’t have head of the bed elevated
Dobhoff: softer, more pliable, causing less nasal trauma, good for a little longer than an NG tube

11. SHORT-TERM FEEDING TUBES
Nasointestinal
Inserted through the nose into the upper portion of small intestine
Helps patients with poor gag reflex or reflux issues
Patient Considerations
Dumping syndrome
Dumping syndrome: hypertonic formula (feeds) is being rapidly administered into the small intestine, causes movement of ECF to move into the intestine—fluid shift
Bypasses pyloric valve in stomach leading to a dumping syndrome
Small intestine gets distended causing gas, bloating, nausea, vomiting, diarrhea, cramps, lightheadedness

12. CONFIRMATION OF TUBE PLACEMENT
Using the nasogastric or nasointestinal route
Confirming NG feeding tube placement
Radiographic examination
Measurement of aspirate pH and visual assessment of aspirate
Measurement of tube length and tube marking
Carbon dioxide monitoring
Confirming nasointestinal tube placement
End tidal CO2 detector: lets nurse know that the tube is not in the lungs, but it can’t determine where tube ends in the GI tract--Xray

13. LONG-TERM FEEDING TUBES
Percutaneous Endoscopic Gastrostomy (PEG) Tube
Inserted into stomach surgically with local anesthesia
Preferred route: gastroesophageal sphincter stays intact, reflux and aspiration less likely
Must have a functioning GI tract
Jejunostomy (j-tube) Tube
Alternate long-term route for patients with gastric problems
Placed surgically with general anesthesia
Low-Profile Gastrostomy Tube (LPGD)
For active patients, children good candidates
No external tubing, easily concealed

14. CONFIRMATION OF TUBE PLACEMENT
PEG, J-tube, LPGD
Requires frequent comparison of tube length from abdominal wall
Measurement should be initially documented after insertion

15. ENTERAL FEEDING ADMINISTRATION
Feeding schedule: Based on medical, physical, and nutritional condition
Continuous
Always used with intestinal tubes to avoid dumping syndrome
Intermittent
Preferred for gastric feedings
Simulates a more normal pattern of intake
Cyclic
Feeding for several hours during a 24 hour period, usually at night
Allows patient to attempt eating regular meals during the day
Intermittent: can be through gravity or feeding pump
Different formulas are available depending on client need (diabetic, renal, etc)

16. ENTERAL FEEDING ADMINISTRATION
Patient Considerations
Check placement
Check gastric residual
Assess abdomen
Position of patient
Medication administration
Patient Comfort
Oral hygiene
Keep nares clean and moist
Pain control
Securement
Checks look for tolerance of feedings: no nausea, vomiting, diarrhea, distention, + bowel sounds

17. COMPLICATIONS OF ENTERAL FEEDING
Aspiration
Clogged tube
Nasal erosion
Diarrhea and other GI symptoms
Extubation
Stoma infection
Extubation: make sure tube is secured!
Clogged tube: flush tube before and after, and q 4hrs during continuous feeds
Aspiration
Clogged tube
Nasal erosion
Diarrhea and other GI symptoms
Extubation
Stoma infection
Patient education for home use is imperative

18. PARENTERAL NUTRITION
The administration of nutritional support through the intravenous route
Who gets PN?
Why do they get PN?
Can be through a central venous access or peripheral venous access
Total Parenteral Nutrition (TPN)
Peripheral Parenteral Nutrition (PPN)
For patients who can’t tolerate oral or enteral feedings
For clients with high nutritional needs: chemo, burns, surgery, multiple fractures, sepsis
GI tract is not functioning, comatose, very high nutritional needs

19. TOTAL PARENTERAL NUTRITION (TPN)
Highly concentrated, hypertonic nutrient solution
Provides calories
Restores nitrogen balance
Replaces necessary vitamins, minerals, electrolytes, fluids
Promotes tissue and wound healing
Lets the bowel and GI system rest
Administered through a central venous access
Always confirm placement of new catheter with an X-Ray
For patients who are expected to have inadequate nutrition for over 1-2 weeks
Common components: dextrose (25% glucose), amino acids, calcium, magnesium, etc.

20. PERIPHERAL PARENTERAL NUTRITION (PPN)
Less concentrated, isotonic nutrient solution
Fewer calories than TPN
For patients who have a malfunctioning GI tract and need nutrition for less than 2 weeks
Can be given through a peripheral access
Only 10% glucose

21. PARENTERAL NUTRITION ADMINISTRATION
TPN
Tailored to individual nutritional needs of the patient
Fat or lipid emulsions and Dextrose can add to calories provided
Usually 25% glucose
PPN
Contains same components as TPN, but in lower concentrations
Usually 10% glucose
Incompatibility
TPN and PPN should not be infused with other fluids or medications
Pharmacist may add glucose and heparin based on patient need
Heparin can be added to reduce fibrin build up in the catheter, prevents clots

22. COMPLICATIONS OF PARENTERAL NUTRITION
Central venous access complications:
Infection
Hyper/hypo- glycemia
Fluid and electrolyte and Acid-Base imbalances
Phlebitis
Hyperlipidemia
Liver and gallbladder disease
CVA- infection, thrombus formation, pneumothorax
Nurse checks?
Vital signs q 4hrs
Glucose checks q 6 hrs
Use the same port on the central line EVERY time
Monitor site dressing (infection risk)
Patient education for home is imperative