1. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Tube Feeding (Relates to Chapter 40, “Nursing Management: Nutritional Problems,” in the textbook)

2. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Oral Feeding High-calorie supplements Used when nutritional intake is deficient Examples include  Milkshakes  Puddings  Ensure, Sustacal Used as snacks

3. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding Also known as enteral nutrition Administration of nutritionally balanced liquefied food or formula through tube inserted into  Stomach  Duodenum  Jejunum

4. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Provide nutrients to GI tract alone or supplemental to oral or parenteral nutrition Easily administered Safer than parenteral More physiologically efficient than parenteral Less expensive than parenteral

5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Indications include those with  Anorexia  Orofacial fractures  Head/neck cancer  Burns  Nutritional deficiencies

6. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Indications include those with  Neurologic conditions  Psychiatric conditions  Chemotherapy  Radiation therapy

7. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Delivery options include  Continuous infusion by pump  Intermittent by gravity  Intermittent bolus by syringe  Cyclic feedings by infusion pump

8. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Common Enteral Feeding Tube Placement Locations Fig. 40-4

9. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding Nasogastric and nasointestinal tubes  Inserted through the nasal cavity  Radiopaque: Allowing visualization from X-ray  ↓ Likelihood of regurgitation and aspiration when placed in intestine

10. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

11. Tube Feeding (Cont’d) Nasogastric and nasointestinal tubes  Can be dislodged by vomiting or coughing  Can be knotted/kinked in GI tract

12. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Gastrostomy and jejunostomy tubes  May be used in those needing tube feedings for extended period Patient must have intact, unobstructed GI tract  Can be placed surgically, radiologically, or endoscopically

13. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Placement of Gastrostomy Tube Fig. 40-5

14. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding Percutaneous endoscopic gastrostomy (PEG) placement requires esophageal lumen wide enough for endoscope PEG and radiologically placed gastrostomy  Fewer risks than surgical placement, lower cost, minimum sedation

15. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Percutaneous Endoscopic Gastrostomy Gastrostomy tube placement via percutaneous endoscopy Using endoscopy, a gastrostomy tube is inserted through esophagus into stomach and then pulled through a stab wound made in abdominal wall Fig. 40-6 A

16. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Percutaneous Endoscopic Gastrostomy (Cont’d) Retention disk and bumper secure the tube Fig. 40-6 B

17. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding Feedings can be started when bowel sounds are present, usually 24 hours after placement Immediately after insertion, tube length from insertion site to distal end should be measured and recorded

18. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Tube should be marked at skin insertion site Insertion length should be checked regularly

19. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Tube feeding administration  Patient position Patient should be sitting or lying with HOB at 30 to 45 degrees HOB remains elevated for 30 to 60 minutes for intermittent delivery

20. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Tube feeding administration  Tube patency Irrigated with water before/after each feeding, drug administration, residual checks Continuous feedings administered on feeding pump with occlusion alarm

21. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  Tube position Placement checked before each feeding/drug administration or every 8 hours with continuous feeds

22. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  Tube position (cont’d) Methods used to check placement Aspiration of stomach contents pH check pH less than 5: Indicative of stomach Most accurate assessment: X-ray visualization

23. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  Tube position (cont’d) Check gastric residual volumes ↑ Volume leads to aspiration

24. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  Formula Before feeding Aspirate gastric contents and measure amount Volume greater than 150 ml and clinical signs of intolerance—feeding held for 1 hour and residual rechecked More than 110% of hourly rate of pump— hold feeding Residual should be given back to patient

25. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  Formula Commercial formulas are preferred to blenderized foods Room/body temperature

26. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  Administration of feedings Pump Gradually increase rate or volume over 24 to 48 hours Intermittent feedings Volume usually 200 to 500 ml per feeding Administer flush water or water boluses as tolerated

27. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d)  General nursing considerations Daily weights Assess for bowel sounds before feedings Accurate I&O Initial glucose checks Label with date and time started Feedings infusing >8 hours discarded Pump tubing changed q24h

28. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Complications  Vomiting  Diarrhea  Constipation  Dehydration More calorically dense, less water formula contains Check for high protein content

29. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding (Cont’d) Gastrostromy or jejunostomy feedings Two potential problems Skin irritation Skin assessment and care Pulling out of tube Education to patient/family regarding feeding administration, tube care, and complications

30. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Tube Feeding Gerontologic Considerations  More vulnerable to complications Fluid and electrolyte imbalances Glucose intolerance Decreased ability to handle large volumes Increased risk of aspiration

31. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study

32. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study 84-year-old male is being discharged from the hospital He was admitted with complications from esophageal cancer

33. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) PEG tube has been placed to allow for tube feedings He lives with his wife, who is 82- years-old Has no other family in town

34. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions 1.What risks are associated with a PEG that you should discuss with him and his wife? 2.What skills must he and his wife learn before discharge?

35. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions (Cont’d) 3.Should any additional patient teaching be done before discharge? 4.How should his response to treatment be managed?