Nutrition

NUTRITION
PRESENTED BY
APARNA C LAKSHMY

DEFINITION
NUTRITION IS DEFINED AS THE PROCESS OF PROVIDING OR
OBTAINING THE FOOD NECESSARY FOR HEALTH AND GROWTH.
NUTRITION IS WHAT A PERSON EATS AND HOW THE BODY
UTILIZES IT

TERMINOLOGY
 ANOREXIA :LOSS OF APPETITE.
 DYSPEPSIA : A FEELING OF
FULLNESS,DISCOMFORT,NAUSEA, AND
ANOREXIA (INDIGESTION)
 DYSPHAGIA : DIFFICULTY IN SWALLOWING
 APPETITE :DESIRE TO EAT
 NAUSEA : A SENSATION OF SICKNESS WITH
INCLINATION TO VOMIT.
 NUTRIENTS : CONSTITUENTS OF FOOD (EG—
CARBOHYDRATE,PROTEIN.
 REGURGITATION : BACK FLOW OF PARTLY DIGESTED
FOOD INTO THE MOUTH FROM THE STOMACH.
 VOMITING : EXPULSION OF STOMACH CONTENTS VIA
THE OESOPHAGUS AND THE MOUTH.

TERMINOLOGY
SATIATE : FEELING OF HAVING EATEN A
SUFFICIENT AMOUNT.
ANOREXIA NERVOSA : IT IS A SERIOUS
,POTENTIALLY LIFE THREATENING EATING
DISORDER CHARACTERIZED BY SELF
STARVATION AND EXCESSIVE WEIGHT LOSS.
BULIMIA NERVOSA : UNCONTROLABLE
COMPELSION TO CONSUME LARGE AMOUNTS
OF FOOD AND EXPEL IT BY SELF INDUCED
VOMITING OR BY TAKING LAXATIVES

Nutrients
Nutrients that provide
energy
Nutrients that support
metabolism
Carbohydrates
Proteins
fats
Minerals
Vitamins
Water

Factors affecting nutritional needs
Development
People in rapid periods of growth (in infancy, and
adolescence) have increased needs for nutrients
Gender
Nutrient requirements are different for men and
women because of body composition and
reproductive functions.
Ethnicity and culture
Ethnicity often determines food preferences
Eg : rice for Asians, curry for Indians

Beliefs about food.
Beliefs about effects of food on health and well
being can affect food choices.
Many people acquire their beliefs about food
television ,magazines, and other media.
Food fads that involve non-traditional food
practices are relatively common.eg:honey is
healthier than sugar, organic foods are always
healthier than those exposed to pesticides.

Personal preferences.
People develop likes and dislikes based on
associations with a typical food (A child who loves
visit his grandparents may love pickle made by
them)
Individuals likes and dislikes can also be related
familiarity.(children often say they dislike a food
before they sample it )

Religious practices
Religious practice also affect diet.
E.g.: some Roman Catholics avoid meat on certain
days
Lifestyle
Certain lifestyle are linked to food –related
behaviours.
People who spend many hours at home may take
time to prepare more meals.People who are always
in a hurry probably eat restaurant meals.

Economics.
What, how much, and how often a person eats
frequently affected by socioeconomic status.
E.g. : people with limited income may not be
to afford meat and fresh vegetables.
Medications and therapy
The effects of drugs on nutrition vary
They may alter appetite, disturb taste perception
interfere with nutrient absorption or excretion(eg :
Some antidepressants increases food intake)

Health
A individual’s health status greatly affects eating
habits and nutritional status.
The lack of teeth, ill- fitting dentures makes
food difficult.
Disease processes and surgery of gastrointestinal
tract can affect digestion,aborption,metabolism,and
excretion of essential nutrients.

Advertising
Food producers try to persuade people to
from product they currently use to the brand of
producer.
Psychologic factors
Some people overeat when stressed ,depressed or
lonely ,others eat very little under the same
conditions.
Anorexia nervosa and bulimia are severe
psychophysiological condition seen most frequently
female adolescents.

FACTORS AFFECTING APPETITE
APPETITE IS INCREASED BY,
Sight and smell of food
Food preference
Physical and mental relaxation
Regularity in eating
Pleasant environment
Exercise

The appetite is decreased by
Physical and mental fatigue
Hurry ,worry and fear
Unpleasant environment and experiences
Lack of exercise
Irregular meals
Long spacing of meal timings

Importance of nutrition
Let food be your medicine and
medicine be your food
Eating a balanced diet is vital for good health
and wellbeing
Diet is as important as medicine in the
treatment of disease.
A modification in the diet or in the nutrients can
cure certain diseases.
E.g. : salt free diet for hypertension

A healthy diet decrease the risk of many diet
related diseases
Food provides energy,protein,essential
fats,vitamins,and minerals to live, grow and function
properly.
Enjoyment of a healthy diet can also be one of
the great cultural pleasures of life

Types of diets served in the hospital.
Full diet
It is a regular, well balanced and normal diet.
It is either vegetarian or non-vegetarian
It is served for patients who do not need any
modification

Soft diet
It is a full diet but consisting of food substances
that are easy to chew and digest.
Particularly for aged patients
E.g. : double boiled rice,riped bananas, steamed
fish,conjee etc.
The pureed diet is a modification of the soft
diet. A puree (or mash) is cooked food, usually
vegetables, or legumes that has been pressed or
,blended to a consistency of a soft creamy paste
or thick liquid

Bland diet
A bland diet is one in which the foods are
easily digestible, free from substances which
might cause irritation of GI tract, and
generally of low roughage content.
The bland diet must be free from all
mechanical and chemical irritants.
For a bland diet ,food should not be fried.

Stimulating foods such as soups ,meat extracts,
strong tea,coffee,alcohol are to be avoided.
Stronger sugar solutions should be avoided.
Avoid fatty foods
Milk should be given in plenty

Liquid diet
Liquid diets must be used for patients who are
unable to take or tolerate solid food.
Types
Clear fluid diet(non residual diet)
Full fluid diet(residual fluid diet)

Clear fluids diet(non residual diet)
Clear fluids are used when there is a marked
intolerance to foods and roughage.
The fluids have particularly no food value, but
can help to maintain the fluid balance of the
body.
E.g. :clear tea, soda water, whey water

Full fluid diet(residual fluid diet)
Full fluid diet is given when the total nutrition of
the patient has to be maintained by fluids for a
considerable time.
This is necessary when a patient is unable to
swallow solid food or if the patient is fed by
tube feeding

Special diets
Many pathological conditions bring about
changes in the body process which necessitates
addition or omission of certain nutrients in the
diet as part of the treatment.
E.g. :low salt or salt free diet, high protein or low
protein diet.

Altered Nutrition
Malnutrition
It is defined as a condition that results from
eating a diet in which nutrients are either not
enough or are too much such that the diet
causes health problems.
It includes both under nutrition and over nutrition.

Over nutrition refers to a caloric intake in
excess of daily energy requirements, resulting in
storage of energy in the form of adipose tissue.
As the amount of stored fat increases, the
individual becomes overweight or obese.
A person is said to be overweight when BMI is
between 25 and 29.9kg/m square. And obese
when BMI is greater than 30kg/m square.

Under nutrition refers to an intake of nutrients
insufficient to meet daily energy requirements
because of inadequate food intake or improper
digestion and absorption of food.
Protein -Calorie Malnutrition.(protein-energy
malnutrition)
It refers to a form of malnutrition where
there is inadequate calorie or protein intake.

Nutritional Assessment
PURPOSE
The purpose of a nutritional assessment is to
identify clients at risk for malnutrition and those
with poor nutritional status.

Nutritional Assessment includes
Anthropometric data
 biochemical data
Clinical
Dietary data

Components of a nutritional
assessment
Anthropometric measurements
Height
Weight
Ideal body weight (IBW)
Usual body weight(UBW)
Body mass index(BMI)
Triceps skinfold(TSF)
Mid arm circumference(MAC)
Mid arm muscle circumference(MAMC)

Anthropometric measurements
IT IS USED TO DETERMINE BODY DIMENSIONS
THEY ARE NON INVASIVE TECHNIQUES
HEIGHT
WEIGHT
Ideal body weight (IBW):A weight that is believed to
be maximally healthful for a person ,based chiefly
height.
(Height(cm) – 100 = weight (kg)
Usual body weight (UBW): Body weight value used to
compare a person’s current weight with his or her
baseline weight.

BODY MASS INDEX:
The BMI is a person’s weight in kilograms divided
by the square of height in meters
WEIGHT IN KILOGRAM
HEIGHT IN METER SQUARE
Eg:patient weight -40 kg, height– 150 cm
150 cm divided by 100 1.5 m
(1.5)2 2.25 m/square.
40 kg 18 kg/m square
 2.25 m square

Normal BMI 18.5 -- 24.9
OVER WEIGHT - 25 - 29.9
UNDERWEIGHT -- LESS THAN 18.5

TRICEPS SKINFOLD
A SKINFOLD MEASUREMENT IS PERFORMED
TO DETERMINE FAT STORES
TO MEASURE THE TSF,LOCATE THE
OF UPPER ARM,THEN GRASP THE SKIN ON THE
BACK OF THE UPPER ARM ALONG THE LONG
AXIS OF THE HUMERUS.
IT IS MEASURED IN MILIMETERS USING SPECIAL
CALIPERS
STANDARD VALUE
MALE -12 MM
FEMALE – 20 MM

The midarm circumference (MAC)
It is a measure of fat, muscle and skeleton
To measure the MAC,ask the client to sit or
stand with the arm hanging freely and
flexed to horizontal. Measure the circumference at
the midpoint of the arm, recording the
measurement in cm.
Standard value:
males– 32 cm
female -- 28 cm

Mid arm muscle circumference(MAMC)
The MAMC is an estimate of lean body mass, or
skeletal muscle reserves.
MAMC = MAC (cm)-- 3.143 TSF(mm)
10
Standard value
Male – 54 cm square
Female -- 30 cm square

Biochemical Data
Laboratory tests provide objective data to the
nutritional assessment.
The tests most commonly used are:
Hemoglobin
Serum albumin
Total lymphocyte count
Serum transferrin level
Urinary urea nitrogen
Urinary creatinine excretion

Clinical assessment
Skin-dry,flaky,scaly,pale,pigmented,presence of
petechiae or bruises,lack of subcutaneous fat,edema
nails –brittle,pale,clubbed,spoon shaped,
 Hair analysis
Dry,dull,sparse,loss of colour,brittle
Mucous membranes-dryness,discolouration
Activity level
Neurological testing—decreased reflexes,sensory
loss,burning,and tingling of hands, and feet,mental
confusion or irritability

Dietary data
24 – hour food recall
For a 24- hour food recall,the nurse asks the client
to recall all the food and beverages the client
consumes during a typical 24- hour period when at
home and evaluating the data obtained by using
food guide pyramid.
Food frequency record is a checklist that
indicates how often general food groups or
specific foods are eaten.
Frequency may be categorized as
times/day,times/week,times/month,or
frequently,seldom, never

A food diary is a detailed record of
measured amounts of all food and fluids a
client consumes during a specific period, usually
3 to 7 days.
A DIET DIARY is a comprehensive time
consuming assessment of a client’s food intake
that involves an extensive interview by a
nutritionist or dietitian.
It may include a 24- hour recall, a food
frequency record and a food diary

Alcohol consumption
Excessive alcohol use contributes to nutritional
deficiencies in a number of ways. Alcohol may
replace food in a person’s diet and it can depress the
appetite.
Excessive alcohol can have a toxic effect on
intestinal mucosa, thereby decreasing the
of nutrients
Alcohol can impair the storage of nutrients and
increase nutrient excretion

Principles of nutrition(principles involved in the diet
therapy)
The diet must be planned in relation to changes
in metabolism occurring as a result of disease.
The diet must be planned according to the food
habits of the patient based on
culture,religion,socio-economic status, personal
preferences(likes and dislikes),physiological and
psychological conditions,hunger,appetite and
satiety.
As far as possible, changes in the diet should be
brought gradually, and adequate explanations are
given with the changes made, if any

In short and acute illness ,the food should not be
forced, because his appetite is very poor but he
may soon recover the normal appetite. But in
prolonged illness it is essential to provide
adequate amount of food to prevent wasting
of tissues
What ever the diet prescribed ,there should be
variety of foods for selection
Small and frequent feeds are preferred to the
usual 3 meals
Hot foods should be served hot and cold foods
should be served cold

General instructions for a nurse in food
service.
The diet should be planned according to
his need, metabolic changes, food habits,
and socio economic status.
See that the patients get the prescribed
diet at the proper time.

She should report the quantity of food
that is left in the tray,the food that is
vomited if any, any signs of allergies
developed after taking food
Create a pleasant environment for a
patient.

The patient should be undisturbed by
treatments,dressings,visitors,doctors rounds,
loud cries of other patients during their meal
times.
Dressings and painful treatments are
finished at least one hour before meal is
served.

Offer bedpans or urinals about half hour
before serving meals.
Avoid strong emotions which may interfere
with digestion by inhibiting the flow of
saliva, gastric and intestinal juice.

Meals should be served in clear and covered
containers
Provision should be made to wash hands, and the
face of the patient before and after the meals.
Remember that a sick person has a poor
appetite .never force for the food.
The food should be cut into small pieces. And is
served one piece at a time.one food after another.

See that the patients appear neat (well
groomed)
Place the patient in a comfortable
position in bed or out of bed. Unless
contra-indicated a fowler’s position is given
with a over bed table.

The bed patient should see the food or they
should be told what food is served in front of
them.
Physical and mental fatigue should be avoided.
If the nurse sits near the patient and
engages in the conversation makes the meal a
pleasure experience for a patient.

Never make hurry to the patient.
The patient should be encouraged to take a
variety of foods.
Fluid requirement should be met to prevent
dehydration.
The nurse should teach the patient and relatives
about well balanced diet, food hygiene.

NURSE’S RESPONSIBILITY IN FEEDING A
HELPLESS PATIENT ORALLY.

PRELIMINARY ASSESSMENT.
1. Check the physician’s orders for any specific
precautions, if any regarding the diet, movement of
the patient, positioning of the patient etc.
2. Plan the diet according to the need of the patient,
his likes and dislikes,socio economic status and
availability of food etc.
3. Ensure that the ordered diet is prepared and is
prepared properly and safely.
4. Find out the food habits of the patient.

articles purpose
A TRAY CONTAINING
MACKINTOSH AND TOWEL TO PROTECT THE BED AND
GARMENTS
FULL PLATE,QUARTER PLATE,CUP
SAUCER,JUGS ETC
TO SERVE THE FOOD
FEEDING CUP TO GIVE THE FLUID TO THE PATIENT.
SPOON ,FORK,KNIFE ETC TO FEED THE PATIENT
A GLASS OF WATER TO OFFER AT THE END OF A MEAL
NAPKIN TO WIPE THE FACE IN BETWEEN
FEEDING CUP WITH WATER AND
KIDNEY TRAY
TO WASH THE MOUTH BEFORE AND
AFTER THE FEED

Preparation of the patient and the unit
Create a pleasant environment.
Avoid visitors
Offer bedpan or urinals half an hour before meal
Position the patient properly.
Help the patient to wash his face and hands
Protect the garments and bed linen with the
mackintosh and towel.

Procedure
Wash hands
Sit by the bedside, usually at the right side of
patient.
Feed the patient slowly, in small amounts, waiting
for him to chew and swallow one mouthful
before giving the next.
Give the foods in order in which they would
normally be eaten by the patient.
Talk pleasantly to the patient as he is eating his
food.

When the patient is blind, they should told what
food they are being given.
Encourage the patient to take all types of foods
served to him.Do not force for the food, which he
dislikes.
When the patient has eaten the food in
sufficient amount,stop feeding and offer a glass of
water.

After care.
Help the patient to wash his mouth ,face and
hands.
Dry the face and hands
Make the patient comfortable
Tidy up the bed
Clean and replace all articles.
Wash hands
Record the procedure.(amount ,type of food,
amount vomited if any, general attitude towards
food)

Special considerations.
Older people(over the age 60)
The energy requirement for older person
decreases in comparison with younger adults as
a result of less physical activity and decreased
basal metabolism.
The requirements for micronutrients do not
decreases. Hence adequate diet for older people
must ensure that micronutrient requirements are
still met even with reduced energy intake.


Sufficient intake of fluids are required to
prevent dehydration and improve
digestion.
They need fewer calories than younger
people, but about the same amount of
protein and other nutrients.
They may need soft food.

Some older adults also need large amounts
of fibre to prevent constipation
Some people may choke on thin fluids like
water. In this case, thick fluids are good.

Pregnant and lactating women
Women’s nutritional need for energy ,protein,
micronutrients significantly increases
Pregnant women require an additional 285
kcal/day.and lactating women require an
500 kcal/day.
Adequate intake of iron,folate,vitamin A ,iodine are
particularly important for the health of both
women and their infants.

Adolescents
They need at least 2 large mixed meals
and some snacks each day.
They can eat bulky food.
Boys need lots of calories.
Girls need plenty of iron.
School aged children (6-12 years)
They need at least 2 to 3 mixed meals and
snacks each day

Infants and young children.
Malnutrition during the early years of life has a
negative impact on cognitive , ,motor,
skill,physical,social,and emotional development
 . Children(1-5 years old)
They need breast milk until they are at least 2 years
old.
They need at least 3 mixed meals and 2 snacks
day.
They cannot eat large bulky meals
It is especially important for the meals to be
and not to contain parasites or microorganisms that
could cause diarrhoea or other infection

Babies (6-12 months)
Need breast milk 8 to 10 times or more
each day.
They need small meals which are not
bulky,3 to 5 times a day
Babies under 6 months old
They need only breast milk at least 8 to
10 times each day.

Enteral nutrition.
Enteral nutrition (EN) also referred to as total enteral
nutrition(TEN) is provided when the client is unable to
ingest foods or the upper GI tract is impaired and the
transport of food to the small intestine is interrupted.
Enteral feedings are administered through
nasogastric,nasoduodenal,nasojejunal feeding tubes, or
through gastrostomy or jejunostomy tubes.
Enteral feeding also known as enteral tube feeding.

Indications for enteral nutrition
Cancer
Head and neck.
Upper GI
Critical illness trauma
Neurological and muscular disorders
Brain neoplasm
Cerebrovascular accident
Dementia
Myopathy
Parkinson’s disease.

Gastrointestinal disorders
Enterocutaneous fistula
Inflammatory bowel disease
Mild pancreatitis
Respiratory failure with prolonged intubation.
Inadequate oral intake.
Anorexia nervosa
Difficulty chewing ,swallowing
Severe depression

Enteral Access tubes.
When patients are unable to ingest food but are
still able to digest and absorb nutrients ,enteral
tube feeding is indicated.
Feeding tubes are inserted through the nose
(nasogastric or nasointestinal),surgically
(gastrostomy or jejunostomy) or
endoscopically(percutaneous endoscopic
gastrostomy or jejunostomy{PEG or PEJ} )

Endoscopically(percutaneous endoscopic gastrostomy or
jejunostomy{PEG or PEJ} )

If EN therapy is for less than 4 weeks, nasogastric or
nasojejunal feeding tubes may be used.
Surgical or endoscopically placed tubes are preferred
for long term feeding (more than 4 weeks)
Most health care settings use small-bore feeding tubes
because they create less discomfort for a patient.
For adults most of these tubes are 8 to 12 Fr and 36-
44 inches(90- 110 cm)long.
A stylet is often used during insertion of small - bore
tube to stiffen it.The stylet is removed when the correct
position of the feeding tube is confirmed.

Enteral feedings
The type and frequency of feeding and amounts
to be administered are ordered by the primary
care provider.
A standard formula provides 1 Kcal per mL of
solution with protein,fat,carbohydrate , minerals,
and vitamins in specified proportions.

Enteral feedings are administered to clients
through open or closed systems.
Open systems use an open-top container or a
syringe for administration.
Closed systems consist of a prefilled container that
is spiked with enteral tubing and attached to the
central access device.
Enteral feedings can be given intermittently or
continuously

Intermittent feedings are the administration of
300 to 500 mL of enteral formula several times
per day. Bolus intermittent feedings are those
that use a syringe to deliver the formula into
the stomach
Continuous feedings are generally administered
over a 24- hour period using an infusion
pump(often referred to as a kangaroo pump)
that guarantees a constant flow rate. Cyclic
feedings are continuous feedings that are
administered in less than 24 hours(eg; 12 to 16
hours)

TUBE FEEDING(GASTRIC
GAVAGE,NASOGASTRIC TUBE FEEDING)
Gavage (gastric) feeding is an artificial
method of giving fluids and nutrients
through a tube, that has passed into the
oesophagus and stomach through the
nose, mouth or through the opening
made on the abdominal wall, when oral
intake is inadequate or impossible.

INDICATIONS FOR TUBE FEEDING
 When the patient is unable to take food by
mouth.eg : unconscious, semiconscious patients.
 For a patient who refuses food.eg: patient with
psychosis.
 When conditions of mouth or oesophagus make
the swallowing difficult or impossible.eg: fracture
of the jaw, surgery of the mouth,throat,and
oesophagus etc.

 When the patient is too weak to swallow food or
when the conditions make it difficult to take a
large amount of food orally.eg: acute and
chronic infections, severe burns, malnutrition etc.
 When the patient is unable to retain the
food.eg : vomiting

Advantages of tube feeding.
An adequate amount of all types of nutrients
including distasteful foods and medications can be
supplied
Large amount of fluids can be given with safety.
The dangers of parenteral feeding are avoided.
Tube feeding may be continued for weeks
without any danger to the patient.
The stomach may be aspirated at any time if
desired.
Overloading of the stomach can be prevented
by a drip method.

Principles involved in
Gastric Gavage

principle Action and Explanation
Tube feeding is a process of
giving liquid nutrients or
medications through a tube
into stomach when the oral
intake is inadequate or
impossible
A thorough knowledge of the
anatomy and physiology of
digestive tract and respiratory
tract ensures safe induction of
the tube
There are many pouches in the
respiratory and digestive tract
where the tube may remain
kinked.so it is necessary to pass
the tube along the curve of the
digestive tract.
The mucus membrane lines the
digestive tract and it can be
injured by friction when the tube
is passed carelessly .

Microorganisms enter the
body through food and drink.
All equipment used for
feeding should be clean.
 The food has to be
prepared,handled,,and stored
under good hygienic
conditions.
The nurse should wash her
hands before preparing the
feeds and feeding patient.
The client who are receiving
tube feeding need frequent
mouth care.

Introduction of the
tube into the mouth or
nostrils is a
frightening situation
and the client will
resist every attempt.
Mental and physical
preparation of the
client facilitates
introduction of the
tube.
Explain the procedure
to the client to win
the confidence and
cooperation.
Explaining the
sequence of the
procedure and
reassurance will remove
the fear.

Systematic ways of working adds
to the comfort and safety of the
client and help in the economy of
material ,time, and energy
Place the client in a comfortable
position.
Check the tube for kinks and
patency.
Prepare the client physically, and
mentally for the tube feeding.
Assemble and arrange articles
before starting the procedure.
Every time before giving the feed,
make sure that the tube is in the
stomach.
Accurate recording of the intake
of food will prevent under nutrition
and malnutrition.

Method of differentiating the
placement of a naso gastric tube
Digestive tract Respiratory tract
During the insertion of tube,
the client will experience no
distress in breathing
The client will have no
difficulty in talking if the tube is
in the digestive tract.
Listen to the distal end of the
tube. No noise will be heard
except a gurgling sound if the
tube has reached the
stomach,
The client may experience
dyspnoea, violent cough and
cyanosis if the tube is in the
respiratory tract.
The client will not be able to
talk, if the tube has passed
through the vocal cord.
A whistling sound is heard ,if
the tube is in the respiratory
tract.

Attach the distal end of the
tube to the syringe barrel or
a funnel and invert it into a
glass of water. A few bubbles
initially or no bubbles indicate
that the tube is in the
digestive tract.
Attach a syringe to the distal
end of the tube and
aspirate. Some gastric fluids
may be withdrawn.
A steady stream of air
bubbles indicate the tube is in
the respiratory tract.
No fluid will be withdrawn if
the tube is in the respiratory
tract.

 Listen over the
stomach with a
stethoscope while
injecting a small
quantity (10 ml) of air
into the tube. Air can
be heard entering
the stomach
 No sound will be
heard.

GASTROSTOMY/ JEJUNOSTOMY FEEDING
This type of feeding had been used when tumours
or operations on the upper alimentary tract make
it impossible for food to reach the stomach and
intestine by the normal route.
A part of the stomach or small intestine is brought
to the abdominal wall and an opening is made
into it through the abdominal wall surgically or
endoscopically.

A tube is inserted into it through which
feedings can be given.
It is essential that the area of the skin around
the tube be kept clean and dry.
Food given through the tube are same as those
given by naso-gastric tube.

Enteral tube feeding complications
Pulmonary aspiration
Diarrhoea
Constipation
Tube occlusion
Tube displacement
Abdominal cramping, nausea ,vomiting
Delayed gastric emptying
Serum electrolyte imbalance
Fluid overload
Hyperosmolar dehydration

problem Possible cause intervention
Pulmonary aspiration
Diarrhoea
Constipation
Tube occlusion
Regurgitation of formula
Feeding tube displacement
Deficient gag reflex
Delayed gastric emptying
Bacterial
contamination,malabsorption
Lack of fibre, lack of free water,
inactivity
Sedimentation of formula, pulverized
medications given per tube.
Verify tube placement, place
patient in high fowler’s position or
elevate head of bed a minimum
of 30 degree during feedings and
for 2 hours afterwards..
Use aseptic practices. Use low fat,
lactose free formula.
Consult with a dietitian,add water
as needed, monitor patient’s ability
to ambulate.
Irrigate with 30 ml water before
and after each medications per tube.
Shake cans well before
administering

Tube displacement
Abdominal
cramping,nausea
vomiting
Delayed gastric
emptying
Coughing, vomiting, not taped securely
High osmolality of formula,lactose
intolerance,intestinal obstruction,high fat
formula,cold formula
Diabetic gastroparesis,serious
illness,inactivity
Confirm placement before
restarting tube feeding, check
that the tape is secure
Use isotonic formula,lactose
free formula,stop feeding
with GI obstruction,use
greater proportion of
carbohydrate,warm formula
to room temperature.
Consult health care
provider,monitor
medications,and pathological
conditions that affect GI
motility.

Serum electrolyte
imbalance
Fluid overload
Hyperosmolar
dehydration
Excess GI losses,dehydration,presence
of disease states such as renal
problem, diabetes mellitus
Excess free water or diluted formula,
Hypertonic formula with insufficient
free water.
Monitor serum electrolyte
levels daily, provide free
water per registered
dietitian recommendation
Restrict fluids if necessary,
use a more concentrated
formula with fluid volume
excess .
Slow rate of delivery,
dilute or change to
isotonic formula

Parenteral Nutrition(intravenous hyper
alimentation(IVH))
Parenteral nutrition is provided when the GI
tract is non-functional because of an
interruption in its continuity or because its
absorptive capacity is impaired.

5. Find out whether any treatment or procedure to
be carried out.
6. Check the general condition of the patient and
the ability for self-care
7. Check the patient’s ability to follow directions.
8. Check the articles available in the patient’s unit.

Purposes.
To provide nutrients required for the normal
metabolism, tissue maintenance, repair and energy
demands
To bypass the GI tract for patients who are unable
to take food orally.

Indications
 Patients who cannot tolerate enteral nutrition because of,
Paralytic ileus
Intestinal obstruction
Acute pancreatitis
Short bowel syndrome
Inflammatory bowel disease
Gastrointestinal fistula
Severe diarrhoea
Persistent vomiting
malaborption

Hypermetabolic states for which enteral therapy is
either not possible or inadequate..
Severe burns
Traumasurgery when nothing can be taken by mouth for
more than 5 days
Acute renal failure
Multiple fractures
Tumour in GI tract.
Patient at risk for malnutrition because of
Gross under weight ( more than 80% below the standard)
Metastatic cancer
NPO for more than 5 days.

Methods of parenteral nutrition
Total nutrient admixture into a central vein(TNA)
This parenteral formula combines carbohydrates in the
form of a concentrated (20 % to 70%) dextrose
solutions, proteins in the form of aminoacids,lipids in the
form of an emulsion (10 % to 20 %) ,including
triglycerides,phospholipids,glycerol, and water,vitamins,and
minerals
It is indicated for patients requiring Parenteral therapy
for seven or more days.
Given through a central vein.

Peripheral parenteral nutrition.
This parenteral formula combines carbohydrates
lesser concentrated glucose solution with
aminoacids,vitamins,minerals,lipids.
Given through a peripheral vein and it is
for patients requiring parenteral nutrition for
fewer than 7 days.

Total parenteral nutrition(TPN)
This Parenteral formula combines
glucose,aminoacids, vitamins, and minerals.
Given through a central IV line. If lipids are
they are given.
Fat emulsion (lipids)
It is composed of triglycerides,(10 %-20%) and
water
May be given centrally or peripherally.

Complications
complication cause intervention
sepsis High glucose content of fluids
Venous access device
contamination
Strict aseptic technique
Monitor temperature,WBC count
and insertion site for signs and
symptoms of infection.
Electrolyte imbalance Iatrogenic
Effect of underlying disease.
E.g.: diarrhoea, vomiting
Monitor for signs and
symptoms of electrolyte
imbalances.
hyperglycemia High glucose content of fluids
Insufficient insulin secretion
Monitor blood glucose
frequently
Decrease glucose content of
fluids .
hypoglycemia Abrupt discontinuation of TNA
administration through a
central vein
After discontinuation of
centrally administratered
TNA,Start 10% dextrose at the
same rate

Hypervolemia
Hyperosmolar diuresis
Hepatic dysfunction
Hypercarbia(hypercapnia)
Lipid intolerance
Iatrogenic
underlying disease such as
congestive heart failure and renal
failure.
High osmolality of parenteral
nutritional fluid
High concentration of
carbohydrates/ fats/protein
High carbohydrate content of
fluid
Low birth weight or premature
infant, history of liver disease
Monitor intake and output,daily
weight,CVP, Breath sounds, and
peripheral edema
Consider decreasing the
concentration or amount of
fluids administered.
Monitor liver function tests,
triglycerides level and presence
of jaundice
Consider changing formula to
increase the proportion of fat
relative to carbohydrates
Monitor liver function,weight,any
allergic reaction,administer lipid
containing solution slowly

Gastric lavage/ stomach wash/gastric irrigation
Definition
Washing out of stomach with a solution using a
lavage set.
Purposes
 To obtain samples of gastric contents for
laboratory studies.
 To relieve nausea and vomiting in case of acute
dilatation of stomach, pyloric stenosis, and
intestinal obstruction

 To confirm levels of bleeding from upper GI tract
and to reduce gastric bleeding.
 To cleanse the stomach as a preparation for
surgery
 To remove poisonous or irritating substances
from stomach.

Solutions used
Plain water
Normal saline
 weak solution of sodium bicarbonate or boric
acid in corrosive poisoning
Specific antidotes: if ingested poison is identified

Articles
Ryle’s tube,specific solution,pint measure,water
soluble lubricant,a funnel,stethoscope,kidney tray,
towel, small mackintosh,clean
gloves,apron,mask,adhesive plaster and
scissors,bucket for return flow,syringe, mouth gag

procedure
Identify patient and check the chart for physician’s order
and any specific instruction.
Explain procedure to the patient.
Wash hands and don gloves
Remove dentures if present and insert a mouth gag(to
prevent biting of the tube),in case of orogastric insertion.
Place patient in left lateral position(prevents aspiration of fluid
into lungs)
Pass lubricated NG TUBE slowly and gently to prevent trauma
to the tissues.
Ensure proper placement of tube.
Secure the tube with adhesive tape.

Attach the syringe to the tube and aspirate the gastric
contents completely and save it for laboratory analysis.
Remove the syringe and attach a funnel to the tube and
fill the funnel with irrigating fluids .Raise the funnel to
allow fluid to run into the stomach. Allow 2-3 funnels of
fluid (150-200 ml) to flow into the stomach.
When 2-3 funnels of fluid have run into the stomach
and before the funnel is completely empty, pinch the
tube ,wait for one minute and invert the funnel over a
receptacle and allow the fluids to return back/ aspirate
using 50 cc syringe.

In case of GI bleeding ,if blood increases in the outflow
,stop the procedure, and inform the physician.
During the procedure observe the patient’s vital signs
and degree of consciousness every 15 mins
Lavaging usually requires a total volume of at least 2
litre.
Discontinue the treatment ,by pinching the tube and
pulling it out quickly.
Leave the stomach empty at the completion of lavage.
Remove the gloves and wash hands

Give a mouth wash and dry the face
Replace articles ,record the treatment with date ,time,
amount of solution used ,character of return flow and
condition of patient before, during, and after the
procedure.
Continue to monitor the patient every 25- 30 minutes
.

Nasogastric suctioning
Removal of stomach contents through a nasogastric tube
by aspiration using low suction
Purposes
To relieve abdominal distention.
To maintain gastric decompression after surgery.
to remove blood and secretions from the gastrointestinal tract
To remove contents of the stomach

To prepare the patient for general anaesthesia
and gastric surgery
To aid in healing of the wound in case of
surgery of the stomach and intestine
Articles
Ryle’s tube,kidney tray for drainage from stomach,20
cc syringe,gauze pieces,clean gloves,towel,pint
measure,basin with water

procedure
Explain procedure to patient
Position patient in semi-fowler’s position
Lower side rails on your side,spread non --
absorbent pad near head end
Wash hands and don gloves
Remove cap from distal end of ryle’s tube and
attach 20 cc syringe to the end by holding it
with a gauze piece.

Aspirate the stomach contents gently
As the syringe is filled with contents pinch the
Ryle's tube disconnect the syringe from the tube
and empty contents into kidney tray.
Continue aspirating till all stomach contents are
aspirated
Disconnect syringe and clamp the Ryle's tube. Rinse
the syringe in a basin of water
Measure the amount of contents aspirated using a
pint measure,
Discard the aspirated contents and wash the pint
measure. Discard the non-absorbent pad

Remove gloves and wash hands
Assist patient for a mouth wash
Document the colour,odour,quantity of contents
aspirated.
Include the amount of contents aspirated in
intake- output chart

Gastric analysis
Gastric analysis consist of a series of tests used to
analyse the contents of the stomach for
acidity,appearance,and volume.
In this procedure, we are aspirating the stomach
contents by introducing a ryles tube into the
stomach and aspirating the stomach contents at
different stages of digestion after giving a specific
meal.
Gastric juice can be aspirated through an oral or
nasogastric tube .

Purposes
For diagnosis of gastric condition.eg: presence of
cancer cells and bacteria
To investigate the emptying capacity of the
stomach
To investigate the stomach secretions such as
hydrochloric acid.

Normal gastric acid secretion - 1500-2000ml/ 24
hour
Gastric juice
A colourless to greyish or yellow watery fluid with
a low specific gravity secreted by the surface
epithelium ,gastric cells and the various glands of
the gastric tract.

Nursing Management.
Assessment
Nursing Diagnosis
planning
Intervention
Implementation
Evaluation

Assessment includes,
Nutritional assessment(ABCD)
. Nutritional screening
Nursing history
Physical examination
Home care assessment

Nutritional screening
A nutritional screen is an assessment performed to
identify clients at risk for malnutrition or those who are
malnourished.
Nurses carry out nutritional screens through routine
nursing histories and physical examinations
Clients who are found to be at moderate or high
are followed with a comprehensive assessment by a
dietitian
Screening tools such as the patient-generated subjective
global assessment(PG-SGA) and nutritional screening
initiative (NSI) can be incorporated into the nursing
history

Summary of risk factors for nutritional
problems.
Diet history.
Chewing or swallowing difficulties
Inadequate food budget
Inadequate food intake
Inadequate food preparation facilities
Inadequate food storage facilities
Intravenous fluids
Living and eating alone
No intake for more than 10 days.
Physical disabilities
Restricted or fad diets

Medical history
 Adolescent pregnancy or closely spaced pregnancies
 Alcohol or substance abuse.
 Catabolic or hyper metabolic condition,eg:burns
 Chronic illness
 Dental problems
 Fluid and electrolyte imbalance
 Gastrointestinal problems
 Neurologic or cognitive impairment
 Oral and gastrointestinal surgery
 Unintentional weight loss or gain of 10 % within 6
months

Medication history
Antacid
Antidepressants
Antihypertensive
Anti-inflammatory agents
Antineoplastic agents
Aspirin
Digitalis
Diuretics
Laxatives
Potassium chloride

Nursing history
Age, sex,and activity level
Difficulty eating
Condition of the mouth, teeth and presence of
dentures
Changes in appetite
Changes in weight
Physical disabilities that affect purchasing,,preparing,
and eating food
Cultural and religious beliefs that affect food choices
Living arrangements and economic status
General health status and medical condition
Medication history

Physical examination
Skin-dry,flaky,scaly,pale,pigmented,presence of
petechiae or bruises,lack of subcutaneous fat,edema
nails –brittle,pale,clubbed,spoon shaped,
 Hair analysis
Dry,dull,sparse,loss of colour,brittle
Mucous membranes-dryness,discolouration
Activity level
Neurological testing—decreased reflexes,sensory
loss,burning,and tingling of hands, and feet,mental
confusion

General appearance -- apathetic, listless,looks tired,easily
fatigued
Weight – over weight, or underweight
Eyes- pale, or red conjunctiva, dryness, soft cornea, dull
cornea, night blindness
Lips - swollen, red cracks at side of mouth, vertical fissures
Tongue- swollen, beefy red, magenta colored,smooth
appearance, decrease or increase in size
Gums- spongy,swollen,inflamed,bleed easily
Muscles-underdeveloped,flaccid,wasted,soft
Gastrointestinal system- anorexia, digestion, diarrhoea,
constipation, enlarged liver, protruding abdomen

Home care assessment
Client / environment
E.g. :Self care abilities, physical environment( water,
electricity, telephone facilities),feeding aids( special
drinking cups,plates,or feeding utensils),
Family
E.g. :Caregiver availability,skills,wiilingness,family role
changes, financial resources and social roles, alternate
potential primary caregivers.
Community
E.g. :Current knowledge, use and experience with
community resources, nutritional counselling services,

Nursing diagnosis
 Imbalanced nutrition more than body requirement
 Imbalanced nutrition less than body requirements
 Readiness for enhanced nutrition
 Risk for imbalanced nutrition: more than body requirements
 Activity intolerance related to inadequate intake of iron-
rich foods resulting in iron- deficiency anemia
 Constipation related to inadequate fluid intake and fiber
intake
 Low self esteem related to obesity
 Risk for infection related to immunosuppression secondary
to insufficient protein intake

Planning
Major goals for clients with or at risk for
nutritional problems include,
Maintain or restore optimal nutritional status
Promote healthy nutritional practices
Prevent complications associated with malnutrition
Decrease weight
Regain specified weight.

Interventions
Determine food preferences with consideration of
cultural and religious preferences
Determine in collaboration with the dietitian –the
number of calories and type of nutrients needed
Provide needed nourishments within limits of
prescribed diet
Structure the environment to create a pleasant and
relaxing atmosphere.

Arrange for appropriate referrals to community
resources that provide meals.
Weigh client at specified intervals
Monitor type and amount of usual exercise.
Determine if client requires nutrition education.

Calculating percentage of usual body
weight.
Current weight 100
usual body weight
Mild malnutrition - 85- 90 %
Moderate malnutrition - 75 - 84 %
Severe malnutrition - less than 74 %

Calculating percentage of weight loss
% of weight loss
 usual weight - current weight 100
Usual weight

Food guide pyramid
The food guide pyramid is a graphic aid that
was developed by the U.S. Department of
Agriculture as a guide in making daily food
choices.

Contraindications for gastric lavage
Corrosive poisoning
Depressed level of consciousness
Hydrocarbons

Contraindications for gastric gavage
Severe midface trauma
Recent nasal surgery
Coagulation abnormality
Esophageal varices

Insertion of a
nasogastric tube

Definition
Insertion of a small bore tube to the stomach
through nasopharynx
Articles.
A tray containing,
1. Kidney tray
2. Mackintosh and towel
3. Cotton tipped applicators
4. Saline

5. Levine’s tube or ryles tube size 8-12 Fr
6. Water soluble lubricant such as glycerine or
liquid paraffin
7. Adhesive plaster and scissors
8. Gauze pieces
9. Clean syringe, size 10-20 ml
10. Measuring cup or marked drinking cup
11. Bowl with water
12. Clamp
13. Suction apparatus
14. Penlight/flash light
15. Tongue blade
16. Glass of water

Procedure
Nursing action rationale
 Identify the patient
 Check the physician’s order
 Check the level of consciousness and
ability to follow instructions
 Ascertain the ability of patient to
maintain desired position during
insertion
 Review the patient’s medical history
for any nasal lesions, bleeding polyps, or
deviated nasal septum
 Wash hands
Help in determining the appropriate size
of the nasogastric tube for patient
Avoids the risk of aspiration of fluid
Facilitates insertion of the tube
May require change in the route of
nutritional support.eg:orogastric insertion
Prevents infection

 Explain procedure to patient
 Explain procedure to patient
 Place patient in a high - fowler’s
position.(comatose patient in semi-
fowler’s position)
 Place mackintosh and towel across
the chest.
 Measure the length of the tube,
That is, from tip of the nose to tip of
the ear lobe and to the tip of xiphoid
process and mark with tape. For oro-
gastric intubation, the tube is measured
from the lips to the tip of xiphoid
process of sternum
Prevents infection
Reduces anxiety and helps patient to
assist in insertion of the tube
Facilitates insertion of the tube and
reduces risk of aspiration
Prevents soiling of patient’s dress
The measured length approximates the
distance from the nose to the
stomach.(for duodenal or jejunal
placement an additional 20-30 cm is
required)

 Cut the adhesive tape 10 cm long
 Put on clean gloves
 Lubricate the tip of the tube
about 6-8 inches with water
soluble lubricant, using a gauze
piece
 Insert the tube through the left
nostril to the back of the throat,
aiming back and down towards the
ear
 Flex the patient ‘s head towards the
chest after the tube has passed
the nasopharynx
For easy accessibility
Prevents contamination from secretions
Lubrication reduces friction between
mucus membrane and the tube.water
soluble lubricant easily dissolves if it
accidentally enter the lungs
Natural contours facilitate the
passage of the tube
Reduces the risk of tube entering the
trachea

 Encourage patient to swallow by giving sips
of water when possible
 Advance tube 3-4 inches each time
patient swallows until desired length has
been passed.Donot force tube. When
resistance is met or patient starts to cough
or choke or become cynosed,stop
advancing tube and pull tube back. Check
the position of the tube in back of throat
with tongue blade
 If there are signs of distress such as
gasping,coughing, or cyanosis,pull back the
tube for some length and check if patient’s
distress is relieved.if it is relieved reinsert
after few seconds.if patient develops
respiratory distress again,immediately remove
the tube
Swallowing closes the epiglottis over the
trachea and facilitates passage of tube into
esophagus
Reduces discomfort and trauma.
The tube may have entered the trachea

 Perform one of the following
measures to check for the
placement of tube.(already
mentioned)
 Examine the patient’s mouth using
a tongue blade and flash light/ pen
light.
 Secure tube with tape and avoid
pressure on nares.
 Fasten end of tube to gown
 Make patient comfortable in bed
and provide oral hygiene every 4-6
hours
The tube may be coiled in the
mouth
Reduces friction on nares when
patient moves
Promotes comfort and integrity of oral
mucous membrane

 Remove gloves, dispose of articles
and wash hands
 Record type of tube placed,aspirate
returned and patient tolerance
Reduce transmission of microorganisms
Document exact procedure.

Nutrition

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