Complex 2 Exam 3
Enteral nursing assessment *** Assessments q 4 hr:
· asses patency Q4: flush with water before/after feedings if not on continuous fluids to loosen any
excess that may clog up tubes
· Assess shape & feel of abdomen (assess for tenderness upon palpation)
· Abdominal x-ray before initial feeding
· Auscultate bowel sounds (all bowel quadrants)
· Stability of tube: look at marker outside of tube
· Monitor I/O & daily weight
· Glucose checks first 24 hr typically q 4-6hrs
Enteral complications *** Dumping syndrome
- Results from emptying of formula too quickly into small intestine, which causes a fluid shift
- May manifest as dizziness, tachycardia, diaphoresis, pallor
Metabolic issues: dehydration, hyperglycemia, electrolyte imbalance, fluid overload, refeeding
syndrome, weight gain
- Provide adequate free water (balance between dehydration & overload), consider change in formula,
monitor labs (electrolyte, glucose), monitor weight, Tx hyperglycemia with insulin
Overfeeding
- N/V, abdominal distention
- Check residual Q4-6
- Hold for residual volumes of 100-200mL then restart at a lower rate
- Ensure the feeding pump is working right
Diarrhea
- D/t concentration of feeding
- Slow the rate & notify provider
,- Provide skin care and increase fiber
- Evaluate for C.Diff if diarrhea continues especially if very foul odor
Enteral complications continued.. *** Aspiration pneumonia - Tube displacement - LIFE THREATENING
- STOP the feeding
- Turn pt to one side, suction airway, provide O2
- Monitor VS for elevated temp
- Auscultate breath sounds
- Notify provider & obtain chest x-ray
Refeeding syndrome - LIFE THREATENING
- When pt is in a starvation state & given enteral feeding, body begins to catabolize protein & fat for
energy
- Monitor for new onset of confusion, seizures, & increased muscular weakness
- Assess for shallow respirations
- Notify provider & obtain blood electrolytes
Enteral nursing interventions *** - Check patency q 4 hrs and before and after use of tube for feeding
- if you need to lay pt down turn feeding off
- HOB at least 30-45 once resumed feeding and up to at least 1 hr after feeding
- Check placement q shift
Aspirate and test the pH of stomach contents
- pH < 4 = tube is in the stomach (gastrostomy tube)
- pH > 6 = tube is in the jejunum (jejunostomy tube)
- Residual checks for NG tubes
,Parenteral composition *** · Amino acids (protein) & glucose (dextrose) make up the base solution
(along with sterile water)
· Electrolytes, minerals, vitamins, & trace elements are added according to client needs
· Lipids (fats) may be added to the solution OR given as a separate intermittent infusion
Parenteral prioritization *** · Always admin via infusion pump to prevent accidental fluid overload NOT
GRAVITY
· TPN must have a filter in tubing to collect particles from solution
· Gradually adjust the flow rate to allow the body to adjust & then keep it consistent (increasing the rate
can lead to overload or hyperosmolar diuresis)
· Monitor BUN
· NEVER abruptly stop TPN --> D/C gradually to prevent rebound hypoglycemia
· CANNOT change the rate after reaching the target rate
- If TPN solution is not available: admin dextrose in water until TPN can be resumed (maybe
D10W...10%-20% dextrose)
Parenteral nursing interventions/complications *** 1. Infection/sepsis: may be a result of contamination
during catheter insertion or contamination solution (high concentration of dextrose=fuel for bacteria)
- Change CVL dressing using sterile technique q 48-72
- Monitor for S/Sx of infection (fever/chills, elevated WBC, redness at cath insertion site)
- Change solution bag & IV tubing Q24
- DO NOT USE TPN LINE FOR OTHER IV BOLUS FLUIDS/MEDS)
- observe the central insertion for local infection (erythema, exudate, tenderness)
2. Hyperglycemia(durin feeding) hypoglycemia(in btwn feeding), electrolyte/vitamin imbalance
- Monitor glucose & admin sliding scale insulin to treat hyperglycemia
- Review Daily labs & get results BEFORE NEW TPN is made (nsulin may be added to the solution by
pharmacy)
- Admin additional dextrose to treat hypoglycemia
, 3. Catheter misplacement leading to pneumo/hemothorax, thrombosis, air embolism
- Monitor for S/Sx of air embolus (sudden respiratory distress, decreased O2 sat, SOB, cough, chest pain,
hypotension)
- Clamp catheter & lay on L side in Trendelenburg to trap air in RA - Admin high flow O2 - Notify provider
4. Fluid overload: TPN is hyperosmotic which can cause FVE
- Monitor daily weight & I/O
-assess lung sounds for crackles
- gradually increase flow rate
Acute abdominal pain: how do all of the below issues manifest in the patient? *** · Appendicitis: RLQ
pain, dull pain around naval area
· Pancreatitis: epigastric pain radiating to back, left flank, or left shoulder pain
· Perforation: severe pain all over abdomen
· Diverticulitis: LLQ pain
· Cholycystitis/Cholelithiasis: RUQ pain radiating to R shoulder
Acute abdominal pain: know the specific clinical manifestations for each disease process *** RUQ
• Liver - Hepatitis
Transplant rejection:
• Duodenal ulcer
• Cholecystitis
RLQ
• Appendicitis
• Crohn's disease
LUQ
• Gastric ulcer
Enteral nursing assessment *** Assessments q 4 hr:
· asses patency Q4: flush with water before/after feedings if not on continuous fluids to loosen any
excess that may clog up tubes
· Assess shape & feel of abdomen (assess for tenderness upon palpation)
· Abdominal x-ray before initial feeding
· Auscultate bowel sounds (all bowel quadrants)
· Stability of tube: look at marker outside of tube
· Monitor I/O & daily weight
· Glucose checks first 24 hr typically q 4-6hrs
Enteral complications *** Dumping syndrome
- Results from emptying of formula too quickly into small intestine, which causes a fluid shift
- May manifest as dizziness, tachycardia, diaphoresis, pallor
Metabolic issues: dehydration, hyperglycemia, electrolyte imbalance, fluid overload, refeeding
syndrome, weight gain
- Provide adequate free water (balance between dehydration & overload), consider change in formula,
monitor labs (electrolyte, glucose), monitor weight, Tx hyperglycemia with insulin
Overfeeding
- N/V, abdominal distention
- Check residual Q4-6
- Hold for residual volumes of 100-200mL then restart at a lower rate
- Ensure the feeding pump is working right
Diarrhea
- D/t concentration of feeding
- Slow the rate & notify provider
,- Provide skin care and increase fiber
- Evaluate for C.Diff if diarrhea continues especially if very foul odor
Enteral complications continued.. *** Aspiration pneumonia - Tube displacement - LIFE THREATENING
- STOP the feeding
- Turn pt to one side, suction airway, provide O2
- Monitor VS for elevated temp
- Auscultate breath sounds
- Notify provider & obtain chest x-ray
Refeeding syndrome - LIFE THREATENING
- When pt is in a starvation state & given enteral feeding, body begins to catabolize protein & fat for
energy
- Monitor for new onset of confusion, seizures, & increased muscular weakness
- Assess for shallow respirations
- Notify provider & obtain blood electrolytes
Enteral nursing interventions *** - Check patency q 4 hrs and before and after use of tube for feeding
- if you need to lay pt down turn feeding off
- HOB at least 30-45 once resumed feeding and up to at least 1 hr after feeding
- Check placement q shift
Aspirate and test the pH of stomach contents
- pH < 4 = tube is in the stomach (gastrostomy tube)
- pH > 6 = tube is in the jejunum (jejunostomy tube)
- Residual checks for NG tubes
,Parenteral composition *** · Amino acids (protein) & glucose (dextrose) make up the base solution
(along with sterile water)
· Electrolytes, minerals, vitamins, & trace elements are added according to client needs
· Lipids (fats) may be added to the solution OR given as a separate intermittent infusion
Parenteral prioritization *** · Always admin via infusion pump to prevent accidental fluid overload NOT
GRAVITY
· TPN must have a filter in tubing to collect particles from solution
· Gradually adjust the flow rate to allow the body to adjust & then keep it consistent (increasing the rate
can lead to overload or hyperosmolar diuresis)
· Monitor BUN
· NEVER abruptly stop TPN --> D/C gradually to prevent rebound hypoglycemia
· CANNOT change the rate after reaching the target rate
- If TPN solution is not available: admin dextrose in water until TPN can be resumed (maybe
D10W...10%-20% dextrose)
Parenteral nursing interventions/complications *** 1. Infection/sepsis: may be a result of contamination
during catheter insertion or contamination solution (high concentration of dextrose=fuel for bacteria)
- Change CVL dressing using sterile technique q 48-72
- Monitor for S/Sx of infection (fever/chills, elevated WBC, redness at cath insertion site)
- Change solution bag & IV tubing Q24
- DO NOT USE TPN LINE FOR OTHER IV BOLUS FLUIDS/MEDS)
- observe the central insertion for local infection (erythema, exudate, tenderness)
2. Hyperglycemia(durin feeding) hypoglycemia(in btwn feeding), electrolyte/vitamin imbalance
- Monitor glucose & admin sliding scale insulin to treat hyperglycemia
- Review Daily labs & get results BEFORE NEW TPN is made (nsulin may be added to the solution by
pharmacy)
- Admin additional dextrose to treat hypoglycemia
, 3. Catheter misplacement leading to pneumo/hemothorax, thrombosis, air embolism
- Monitor for S/Sx of air embolus (sudden respiratory distress, decreased O2 sat, SOB, cough, chest pain,
hypotension)
- Clamp catheter & lay on L side in Trendelenburg to trap air in RA - Admin high flow O2 - Notify provider
4. Fluid overload: TPN is hyperosmotic which can cause FVE
- Monitor daily weight & I/O
-assess lung sounds for crackles
- gradually increase flow rate
Acute abdominal pain: how do all of the below issues manifest in the patient? *** · Appendicitis: RLQ
pain, dull pain around naval area
· Pancreatitis: epigastric pain radiating to back, left flank, or left shoulder pain
· Perforation: severe pain all over abdomen
· Diverticulitis: LLQ pain
· Cholycystitis/Cholelithiasis: RUQ pain radiating to R shoulder
Acute abdominal pain: know the specific clinical manifestations for each disease process *** RUQ
• Liver - Hepatitis
Transplant rejection:
• Duodenal ulcer
• Cholecystitis
RLQ
• Appendicitis
• Crohn's disease
LUQ
• Gastric ulcer
