Nutrition last (1).ppt

Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition
Audrey Berman • Shirlee Snyder
Nutrition
47

Learning Outcomes
1. Define nutrition, nutrients, energy balance.
2. Identify factors influencing nutrition.
3. Identify nutritional variations among adults.
4. Discuss essential components and purposes of nutritional
assessment and nutritional screening.

Learning Outcomes (cont'd)
5. Identify risk factors for and clinical signs of malnutrition.
6. Describe nursing interventions to promote optimal nutrition.
7. Discuss nursing interventions to treat clients with nutritional
problems.

Learning Outcomes (cont'd)
9. Plan, implement, and evaluate nursing care associated with nursing
diagnoses related to nutritional problems.
10. Demonstrate appropriate documentation and reporting of
nutritional therapy
11. Verbalize the steps used for:
a) Measuring body weight and height
b) Inserting a nasogastric tube
c) Removing a nasogastric tube
d) Administering a tube feeding

Introduction
Nutrition is the sum of all the interactions
between an organism and the food it consumes

Introduction
Nutrients: organic and inorganic substances found in foods that
are required for body functioning
• organic nutrients: carbohydrates, fats, proteins, and vitamins
• inorganic nutrients: dietary minerals, oxygen, water

Introduction
Foods differ greatly in their nutritive value (nutrient
content of specified amount of food)
http://www.sparkpeople.com/resource/food_lists_s
nacks.asp

Essential Nutrients
•Most basic nutrient needed: water
•Next, nutrients that provide fuel or energy:
(carbohydrates, fats, proteins)

Energy Balance
•Energy Balance: Relationship between
energy derived from food and energy
used by body
•energy intake vs. energy output

Energy Balance
•Body obtains energy in form of calories
from carbohydrates, proteins, & fats
•Body uses energy for voluntary activities
such as walking, talking and for
involuntary activities such as breathing
and secreting enzymes

Energy Balance
Energy intake: Amount of energy that foods
supply to body is caloric value
https://www.momsteam.com/nutrition/sports-
nutrition-basics/nutritional-needs-
guidelines/carbohydrate-and-calorie-content-of-foods
Energy output : Metabolism refers to all
biochemical & physiological processes by which
body grows & maintains itself

Energy Balance
Rate of heat liberated during chemical reaction
is metabolic rate.
•Basal metabolic rate (BMR) is rate at which
body metabolizes food to maintain energy
requirement of a person who is awake & at rest

Factors Influencing Nutrition
• Development
• Gender
• Ethnicity and culture
• Beliefs about food
• Personal preferences
• Religious practices
• Lifestyle
• Economics
• Medications and therapy
• Health
• Alcohol consumption
• Advertising
• Psychological factors

Factors affecting nutrition
Development:
•Adolescence rapid period of growth with increased
needs for nutrients.
•Older adults need fewer calories and need some
dietary changes with their increased risk for CHD,
osteoporosis, & hypertension

Gender:
•Nutrient requirements differ between males &
females (body composition and reproductive
functions).
•Larger muscle mass in men means greater needs for
calories and proteins
•Females need more iron than men prior to
menopause
•Pregnant and lactating women have ↑ fluid &
caloric needs

Ethnicity and culture:
Ethnicity determines food preferences
•However, universally accepted guidelines:
Eat a wide variety of foods to supply adequate
nutrients
Eat moderately to maintain body weight

Beliefs about food
•Beliefs about effects of foods on health can affect food
choices; people acquire their beliefs from television,
magazines, and other media.

Personal preferences:
• People develop likes and dislikes based on associations with foods
(foods prepared by mother or grandmother) and are sometimes
carried through adulthood; likes and dislikes can also be related to
familiarity
• Preferences in tastes, smells, flavors, temperatures, colors,
shapes, and sizes of food influence person’s food choices; textures
also play great role in food preferences

Lifestyle:
Certain lifestyles are linked to food-related behavior
(people who stay at home prepare foods from
scratch; people in a hurry might eat more ready-
made meals)
Muscular activity affects metabolic rate more than
any other factor

Economics:
What, how much, and how often a person eats is
affected by socioeconomic status; also affected:
food preparation and food storage facilities

Medications and therapy:
• Some medications may change appetite, disturb taste perception
or interfere with nutrient absorption or excretion
• Some nutrients can decrease drug absorption; others enhance
absorption
• Older adults are at increased risk for drug-food interactions due to
number of medications they take, decrease in renal or hepatic
functions, and age-related changes
• Chemotherapy may adversely affect eating patterns and nutrition

Table 47-1 Selected Drug–
Nutrient Interactions

Health:
•Client’s health status: missing teeth, ill-fitting dentures
& dysphagia can prevent person from getting adequate
nourishment
•Disease processes & surgery of GI tract can affect
digestion, absorption, metabolism and excretion;
create nausea, vomiting, and diarrhea
•Gallstones (affecting flow of bile) will affect lipid
digestion

Alcohol consumption:
•Alcohol has large number of calories, can lead to
weight gain; excessive alcohol use contributes to
nutritional deficiencies, can depress appetite, toxic
effect on intestinal mucosa leading to decrease in
absorption of nutrients

Advertising: influences people’s food choices and
eating patterns to some extent.
•Advertising targets products such as coffee, frozen
foods and soft drinks more than advertising breads,
vegetables and fruits
•Australia, Canada, Sweden and England have
adopted regulations prohibiting food advertising on
programs targeting young children

Factors Influencing
Nutrition
Psychological factors.
• Psychological status may affect
eating patterns
• Anorexia and weight loss can
indicate severe stress or
depression
• In female adolescents: bulimia
(binge eating and purging);
anorexia nervosa (distorted
body self-perception, food
restriction, inappropriate
eating habits or rituals,
obsession with having thin
figure, irrational fear of weight
gain)
https://www.youtube.com/watch?v=ltf_N7ZhPv8

Nutritional Variations
•Adolescents
•Increased need for nutrients and calories during
growth spurts (protein, Ca, vitamin D, Fe and B
vitamins)
•Have active lifestyles and irregular eating
patterns
•Encourage healthy snacks and limit junk foods
•Common problems: obesity, anorexia nervosa
and bulimia

Nutritional
Variations (cont’d)
• Young adults
• Nutritional habits established earlier
• Need help in knowing how many
servings of each food group is needed
• Young adult females need adequate
Fe intake (iron-rich foods: organ
meats, eggs, fish, poultry, leafy
vegetables, and dried fruits) to
prevent Fe deficiency anemia; folic
acid supplements for all women of
child-bearing ability (to prevent
neural tube defects in fetus)

Nutritional Variations (cont’d)
•Young adults (cont.)
• Adequate intake of Ca to maintain bones and decrease
chances of osteoporosis in later life
• Adequate intake of vitamin D, necessary for entry of Ca into
bloodstream; if no sufficient sun exposure, supplements
indicated
• Obesity common in sedentary adults: at risk of hypertension

Nutritional Variations (cont’d)
Middle-aged adults
• Continue to eat healthy diet, special attention to protein and calcium
intake & limit cholesterol and caloric intake
• 2-3 liters of fluid in daily diet
• Postmenopausal women need to take sufficient Ca and vitamin D to
reduce osteoporosis; antioxidants such as vitamins A, C, and E reduce
risk of heart disease in women
• At risk of obesity, reduce caloric intake and do regular exercise; also
at risk for DM, hypertension, and arthritis

Nutritional Variations (cont'd)
Older adults
•Require same basic nutrition as younger adult,
but fewer calories due to lower metabolic rate
and decrease in physical activity
•Some may need more carbohydrates for fiber and
bulk, but most nutrient requirements remain
relatively unchanged

Nutritional Variations (cont'd)
Older adults (cont.)
•Physical changes as teeth loss and impaired sense
of taste and smell may affect eating habits
•Decreased saliva and gastric juice secretion may
also affect nutrition
•Psychological factors such as depression, loss of
spouse, empty nest may result in poor dietary
habits
•Factors such as lack of transportation, poor access
to stores, and inability to prepare food, lowered
income also affect nutritional status

Standards for healthy diet
•Various daily food guides have ben developed to help
healthy people meet the daily requirements of
essential nutrients and to facilitate meal planning
U.S. Department of Agriculture's Food Guidance System
(MyPlate, MyPyramid)

Standards for healthy diet
Myplate
•Introduced in 2011 as simpler reminder of how to
implement dietary guidelines
•Promotes getting more fruits and vegetables, whole
grains, and low-fat diary foods into diet

Altered Nutrition
•Malnutrition: lack of necessary or appropriate food
substances; includes both
over nutrition and undernutrition

Altered Nutrition
•Over nutrition: caloric intake in excess of daily energy
requirements, resulting in fat storage leading to
overweight or obesity which predisposes to chronic health
problems. If obesity affects mobility /breathing, it is called
morbid obesity

Altered Nutrition
•Undernutrition: intake of nutrients insufficient to meet
daily energy requirements because of inadequate food
intake or improper digestion & absorption of food
Inadequate nutrition results in weight loss, weakness,
delayed wound healing, altered functional ability,
susceptibility to infection, impaired pulmonary
function, prolonged hospital stay

Assessing
•Responsibility of nutritional assessment: primary
care provider, dietician and nurse

Nutritional Screening and Assessment
(cont’d)
•Nutritional screening
•Nursing history
•Anthropometric measurements
•Biochemical (laboratory) data
•Physical examination
•Dietary data

Nutritional Screening and Assessment
(cont’d)
•Nutritional screening
•comprehensive nutritional assessment is time
consuming and expensive, other types of assessment
done
Nutritional screen: performed by nurses to
identify clients at risk for malnutrition or those
who are undernourished (done through routine
nursing history and physical examination); those
with moderate or high risk for malnutrition, f/u
with comprehensive assessment by dietitian

Box 47-7 Nutritional Screening Tool

Nutritional Screening
Nursing history: obtained in routine admission
nursing history
•age, sex, activity level
•difficulty eating (impaired chewing or swallowing)
•condition of teeth, mouth, dentures
•changes in appetite
•changes in weight

Nursing history (cont.)
•physical disabilities that affect purchasing,
preparing and eating
•cultural and religious beliefs
•living arrangements (living alone), economic status
•general health status & medical condition
•medication history

•Anthropometric measurements (anthropometry: scientific
study of the measurements and proportions of the human body)
Anthropometric measurements are noninvasive
techniques that aim to quantify body composition:
Height and weight (nursing skill)
Skin fold measurement (non nursing skill)
Mid-arm circumference (non nursing skill)
Mid-arm muscle area (non nursing skill)

Biochemical (Laboratory) Data
Most common tests:
•Serum proteins
•Urinary tests: urinary urea nitrogen & urinary
creatinine
•Total lymphocyte count

Serum proteins
•Serum protein levels give estimate of visceral
protein stores
Tests include: hemoglobin, albumin, and
transferrin, total lymphocyte count

Serum proteins
•Low hemoglobin level may be evidence of iron
deficiency anemia
rule out: abnormal blood loss or pathologic process like
GI cancer

Serum proteins
• Albumin: accounts for over 50% of total serum protein;
albumin half life of 18-20 days, so albumin concentrations
change slowly; thus, low serum albumin level is indicator of
prolonged protein depletion. However other reasons for
decreased albumin concentration: altered liver function,
hydration status and losses from open wounds and burns

Serum proteins
• Transferrin binds & carries iron from intestine through
the serum. With its shorter half-life than albumin (8-9
days), transferrin responds more quickly to protein
depletion than albumin
• Transferrin levels below normal are found with protein
loss, Fe deficiency anemia, pregnancy, liver dysfunction

Serum proteins
•Total lymphocyte count
The total number of lymphocyte white blood cells decreases as protein
depletion occurs

Urinary tests
• Urinary urea & urinary creatinine are measures of
protein catabolism & the state of nitrogen balance
• Urea: chief end product of amino acid metabolism, is
detoxified by liver, circulated in blood, and transported to
kidneys for excretion in urine; urea concentrations in
blood & urine directly reflect intake & breakdown of
dietary protein, rate of urea production in liver and rate of
urea removal by kidneys

Urinary tests
•Urinary creatinine reflects person’s total muscle mass;
the greater the muscle mass, the greater the excretion
of creatinine; as skeletal muscle atrophies during
malnutrition, creatinine excretion decreases

Nutritional Assessment
Clinical data (physical examination)
Assessment focuses on skin, hair, nails, eyes,
and mucosa

Clinical data (physical examination)
•Calculating percentage of weight
loss: (compare current body weight with usual body
weight; any weight loss or gain, duration and if intentional or
unintentional)

Body weight and body mass standards
•Maintaining healthy or ideal body weight
requires balance between expenditure of
energy and intake of nutrients
•When energy requirements of an individual
equate with the daily caloric intake, body
weight remains stable

Measuring body weight
Electronic scale
https://www.youtube.com/watch?v=9xYwUqUVKr8&list=PL5F
5C0CBEE7315048&index=2 (go to 1:11-end)
https://point-of-
care.elsevierperformancemanager.com/skills/19429/quick-
sheet?skillId=GNMS_59#scrollToTop (no video, quick sheet)
Physician Mechanical Beam Scale
https://www.youtube.com/watch?v=BpY7xDZ_1Cg Time 2:32

Measuring height
Stadiometer (Frankfort horizontal plane)
https://www.youtube.com/watch?v=0LNCuP24
MSc&list=PL5F5C0CBEE7315048&index=3 Time
0-2:22

Ideal body weight: optimal weight
recommended for optimal health; consult
standardized tables.
https://globalrph.com/medcalcs/adjusted-
body-weight-ajbw-and-ideal-body-weight-
ibw-calc/

IBW

• Many health professionals consider body mass index (BMI)
to be more reliable indicator of person's healthy weight
• For people older than 18 years, BMI is indicator of changes
in body fat stores and whether person’s weight is
appropriate for height
• Caution: results must be used with caution in people with
fluid retention, athletes, or older adults
BMI = weight (kg)
(height in meters)²

BMI

Other Measures
• Percent body fat (men 6-19%; women 13-31%)
https://www.youtube.com/watch?v=saR8zNPRTio

Other Measures
• Waist circumference (skill not required of you)
https://www.youtube.com/watch?v=KacU_TW50Zo&feature=rel
mfu (0.51 of video)

Other Measures
• Skinfold testing (skill not required of you)

Other Measures
• Bioelectrical impedance analysis: to estimate body fat, it
determines the electrical impedance, or opposition to the flow
of an electric current through body tissues which can then be
used to estimate total body water (TBW), which can be used to
estimate fat-free body mass and, by difference with body
weight, body fat
https://www.youtube.com/watch?v=vTcUS3qCLSU

Bioelectrical impedance analysis

•Dietary data (client’s usual eating patterns
and habits, food preferences, allergies, and
intolerances)
24-hr food recall: typical 24-hr food recall when at home

Dietary data (cont.)
food frequency record: checklist that indicates how
often general food groups or specific foods are eaten,
could be times/day, or times/week, times/month, seldom,
or never; no indication here of quantities consumed, only
types of foods

•Dietary data (cont.)
food diary: detailed record of measured
amounts of all foods and fluids consumed
during specified period, usually 3-7 days
diet history: comprehensive time
consuming assessment of client’s food
intake done by nutritionist or dietitian

NANDA Nursing Diagnoses
•Related to nutritional problems:
•Imbalanced Nutrition: Less Than Body
Requirements
•Obesity
•Overweight
•Readiness for enhanced nutrition
•Feeding Self-Care Deficit

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

Implementing
•Hospitalized Client
Provided in collaboration with the primary care
provider and the dietician
•Reinforce information presented by dietician
•Create an atmosphere that encourages eating
•Provide and assist with eating
•Monitor the client’s appetite and food intake
•Administer enteral and parenteral feedings
•Consult with primary care provider and dietician
about nutritional problems

Implementing
•Assisting with diet: for hospitalized
clients
regular diet 2,000 Kcal menu to
choose from

Implementing
•Assisting with diet: for hospitalized clients
light diet (postoperative/those not ready
for regular diet): plainly cooked, minimal
fat & lots of fiber.
Diets include: clear liquid, full liquid, soft
diet, & diet as tolerated.

Implementation
Clear liquid diet (Box 47-8)
• Limited to water, tea, coffee, clear
broths, strained and clear juices, and
plain gelatin, carbonated beverages
• Supplies client with fluid and
carbohydrates (in form of sugar) but not
adequate protein, fat, vitamins, minerals
or calories
• It is a short-term diet (24 to 36 hours)
provided to clients after surgeries or in
acute stages of infection, especially of GI
tract
• Major objectives of this diet: relieve
thirst, prevent dehydration, and
minimize stimulation of GI tract

Implementation
Full liquid diet (Box 47-8)
•Contains only liquids or foods that turn into liquid at body
temperature, e.g.: ice cream, yogurt, custards
•For client with GI disturbances or who cannot tolerate
solid or semisolid foods.
•Not recommended long-term: low in Fe, protein, calories;
cholesterol content high due to cow’s milk

Implementation
Soft diet (Box 47-8)
•Easily chewed & digested, for clients with difficulty
chewing and swallowing,
•Low fiber diet; soft /semisoft diet e.g., pureed diet

Implementation
Diet as tolerated
•Ordered when client’s appetite, ability to eat and
tolerance for certain foods may change
•Example,
on first postoperative day, clear liquid diet
if no nausea, active bowel sounds, client reports passing gas
and feels like eating, advance to full liquid, light or regular diet

Box 47-9 Examples of Foods for Clear
Liquid, Full Liquid, and Soft Diets

Assisting Clients with Meals
85

• Clients who frequently need assistance with their meals include:
Older adults who are weakened
Individuals with disabilities such as visual impairment (use clock system to
describe location of food on plate) Box 47-10
Clients who must remain in back-lying position
Clients who cannot use their hands
• Whenever possible, nurse should help clients feed themselves rather
than feed them
86

Figure 47-11 For a client who is blind, the nurse can
use the clock system to describe the location of food on
the plate.

• Nurses should try to appear unhurried and convey that they have ample time
• Ask client in which order he likes to eat the food (if client cannot see, tell client
which food is being given)
• Always allow ample time for the client to chew and swallow the food before
offering more
• Also, provide fluids as requested or, if the client cannot communicate, offer fluids
after every three or four mouthfuls of solid food.
• Make mealtime a pleasant one, choosing topics of conversation that are of
interest to clients who want to talk
• Although normal utensils should be used whenever possible, special utensils
may be needed to assist a client to eat and promote independence
88

Figure 47-12 Left to right: glass holder,
cup with hole for nose, two-handled cup
holder.

Figure 47-13 Dinner plate with guard
attached and lipped plate facilitate
scooping; wide-handled spoon and knife
facilitate grip.

Box 47-11 Providing Client Meals

Enteral Nutrition
•When client cannot ingest foods or upper GI tract is
impaired and transport of food to small intestine is
interrupted , alternative feeding methods that
ensure adequate nutrition include enteral (through
GI system) methods

Enteral access devices
•Achieved through:
1. Nasogastric or nasointestinal tubes
or
2. Gastrostomy or jejunostomy tubes

NGT

NGT, Gastrostomy, Jejunostomy Tube

Purposes of Nasogastric Tube
Insertion
96

Purposes
Nasogastric
Tube Insertion
• To administer tube feedings and medications to clients
unable to eat by mouth or swallow a sufficient diet without
aspirating food or fluids into the lungs
• To prevent nausea, vomiting, and gastric distention
following surgery. In this case, the tube is attached to a
suction source
• To remove stomach contents for laboratory
analysis
https://www.msdmanuals.com/professional/gastrointestinal-disorders/diagnostic-and-therapeutic-gastrointestinal-
procedures/gastric-analysis
• To lavage (wash) the stomach in case of poisoning or
overdose of medications

Enteral Nutrition
•Nasogastric tube inserted through one of nostrils,
down nasopharynx and into alimentary tract placed
into stomach.

Indications for nasogastric tube
•Feed clients with adequate gastric emptying and
who require short-term feedings
Not advised for feeding clients without intact gag
and cough reflexes because risk of accidental
placement of tube into the lungs is much higher in
those clients
99

Inserting a Nasogastric Tube
Swallowing closes the epiglottis.

Enteral Nutrition
Nasogastric Tubes
• Feeding tubes come in various sizes.
• Larger tubes may be needed to pass medications
without clogging.
• Smaller, more flexible ones are more comfortable for
the patient.
101

Inserting a Nasogastric Tube
Measuring the appropriate length to
insert a nasogastric tube.

Inserting a Nasogastric Tube Taping a
nasogastric tube to the bridge of the
nose.

Enteral Nutrition
Nasogastric Tubes
Traditional firm, large-bore
nasogastric tubes
• Levin tube, flexible rubber
or plastic, single-lumen
tube with holes near the
tip
• Salem sump tube, with a
double lumen
104
Single-lumen Levin tube
Double-lumen Salem
sump tube with filter on
air vent port and
connector on suction
port

Enteral Nutrition
Nasogastric Tubes
•Softer, more flexible and less irritating
small-bore feeding tubes , smaller than
12 Fr in diameter, are frequently used for
enteral nutrition
105

Enteral Nutrition
•Nasoenteric (nasointestinal) tube is
longer tube than NGT (at least 40 cm for
an adult), inserted through one nostril
down into upper small intestine.

Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
Figure 47-15 (continued) Nasoenteric feeding tubes: B, 8 Fr opaque, 45 in., stylet, weighted tip. Note that both have
a Y-port connector to permit irrigation and medication administration without disconnecting the feeding device.
B

Purposes
Nasoenteric (nasointestinal) Feeding
Used for clients at risk for aspiration, such as
those with:
1.Decreased level of consciousness
2.Poor cough or gag reflexes
3.Inability to participate in procedure
4.Restlessness or agitation

Enteral Nutrition
•Gastrostomy and jejunostomy devices used for
long-term nutritional support, generally more than
6-8 weeks
•Tubes placed surgically or by laparoscopy through
abdominal wall into stomach (gastrostomy) or
jejunum (jejunostomy)

Enteral Nutrition
• A percutaneous endoscopic gastrostomy (PEG) or percutaneous
endoscopic jejunostomy (PEJ) is created by using an endoscope to
visualize the inside of the stomach, making a puncture through the skin
and subcutaneous tissues of the abdomen into the stomach, and inserting
the PEG or PEJ catheter through the puncture.
Percutaneous endoscopic
gastrostomy (PEG) tube

Enteral Nutrition
• The surgical opening is sutured tightly around the tube or catheter to
prevent leakage. Care of this opening before it heals requires surgical
asepsis.
• The catheter has an external bumper and an internal inflatable retention
balloon to maintain placement.
• When the tract is established (about 1 month), the tube or catheter can be
removed and reinserted for each feeding. Alternatively, a skin-level tube
can be used that remains in place
Low-profile gastrostomy feeding tube

Testing feeding tube placement
•Before feedings are introduced, tube placement
is confirmed by radiography, particularly when a
small-bore tube has been inserted or when the
client is at risk for aspiration.
•After placement is confirmed, nurse marks the
tube with indelible ink or tape at its exit point
from the nose and documents the length of
visible tubing for baseline data.

•The nurse is responsible for verifying tube
placement (i.e., GI placement vs. respiratory
placement) before each intermittent feeding and at
regular intervals (e.g., at least once per shift) when
continuous feedings are being administered

•To check tube placement, radiographic
verification of tube placement is done
(definitive method); however repeated x-
ray studies are not feasible in terms of
cost and exposure of client to radiation.

•Methods nurses use to check tube
placement include the following:
1. Injecting air
2. Aspirate GI secretions
3. Measure pH of aspirated fluid
4. Test aspirate for bilirubin. Bilirubin levels in lungs
should be almost zero, while levels in the stomach
will be approximately 1.5 mg/dL and in intestine
more than 10 mg/dL
5. Confirm length of tube insertion

1. Inject Air
Inject 10-30 mL of air into tube while listening with stethoscope for whooshing sound
over epigastrium (below sternum and above umbilicus)
2. Aspirate GI secretions
Because small-bore tubes offer more resistance during aspirations than large-
bore tubes and are more likely to collapse when negative pressure is applied, it
may not be possible to obtain an aspirate. If obtained, gastric secretions tend to
be a grassy-green, off-white, or tan color; intestinal fluid is stained with bile and
has a golden yellow or brownish green color.

3. Measure pH of aspirated fluid
Testing the pH of aspirate can help distinguish gastric from respiratory and
intestinal placement as follows:
• Gastric aspirates tend to be acidic and have a pH of 1 to 4 but may be as
high as 6 if the client is receiving medications that control gastric acid.
• Small intestine aspirates generally have a pH equal to or higher than 6.
• Respiratory secretions are more alkaline with values of 7 or higher.
However, there is a slight possibility of respiratory placement when the pH
reading is as low as 5.
• Therefore, when pH readings are 5 or higher, radiographic confirmation of
tube location needs to be considered, especially in clients with diminished
cough and gag reflexes.

4. Confirm length of tube insertion
• Confirm length of tube insertion with the insertion mark.
If more of the tube is now exposed, the position of the
tip should be questioned.

More research is required to devise effective alternatives to radiographic
verification of tube placement, especially for placement of small-bore tubes.
In the meantime, nurses should:
(a) ensure initial radiographic verification of small-bore tubes
(b) aspirate contents when possible and check their acidity
(c) closely observe the client for signs of obvious distress
(d) consider tube dislodgment after episodes of coughing, sneezing, and
vomiting.

Enteral feedings
Purpose:
1. To restore or maintain nutritional status
2. To administer medications
Assessment:
1. For any clinical signs of malnutrition or dehydration
2. For allergies to any food in the feeding
3. For presence of bowel sounds
4. For any signs of lack of tolerance to previous feedings
121

Enteral Feedings
• Type and frequency of feedings and
amounts to be administered are
ordered by physician.
• Liquid feeding mixtures are available
commercially or may be prepared by
the dietary department in accordance
with the physician’s orders
• A standard formula provides 1 Kcal
per milliliter of solution with protein,
fat, carbohydrate, minerals, and
vitamins in specified proportions.
122

Enteral Feeding
•Enteral feedings can be given:
- intermittently
or
- continuously

Enteral Feeding
•Enteral feedings can be given:
- intermittently (administration 300-500 mL of
enteral formula several times per day, over at least
30 minutes, into stomach; bolus intermittent
feedings are not recommended as it is rapid), or

Enteral Feeding
Enteral feedings can be
given:
-continuously
(administered over 24-
hour period using infusion
pump (kangaroo pump)
that guarantees constant
flow rate; no more than
60 mL/hr)

Enteral Feeding
Assess residual feeding contents
1. If the tube is placed in the stomach, aspirate all contents
and measure the amount before administering the
feeding
Rationale: to evaluate absorption of the last feeding;
whether undigested formula from a previous feeding
remains. If tube is in small intestine, residual contents
cannot be aspirated.
126

Enteral Feeding
2. If 100 mL (or more than half of the last feeding) is withdrawn, check
with the nurse in charge or refer to agency policy before you proceed. The
precise amount is usually determined by the primary care provider’s order
or by agency
Rationale: At some agencies, a feeding is delayed when the specified
amount
Or
3. Reinstill the gastric contents into the stomach if this is the agency policy
or primary care provider’s order
Rationale: Removal of the contents could disturb the client’s electrolyte
balance.
127

Enteral Feeding
4. If the client is on continuous feeding, check the gastric residual
every 4 to 6 hours or according to agency protocol
128

Enteral Feeding
• Enteral feedings administered through:
-open systems (use open-top container or syringe for administration;
enteral feedings used with open systems are provided in flip-top cans or
powdered formulas that are constituted with sterile water. Open systems
should have no more than 8-12 hours of formula poured at one time; at
the end of these hours, remaining formula should be discarded and
container rinsed before new formula is poured); bag and tubing should be
replaced q 24 hours)
-closed systems (prefilled container attached to enteral access device, can
hang safely for 48 hours)

130
Closed system

Enteral Feedings
•Before administering a tube feeding, nurse must
determine any food allergies of client and assess
tolerance to previous feedings
•Also nurse must assess expiration date on
commercially prepared formula or preparation date
and time of agency-prepared solution and discard
any formula that has expired or that was prepared
more than 24 hours previously
131

Enteral Feedings
• Feedings are usually administered at room temperature unless the
order specifies otherwise
• The nurse warms the specified amount of solution in warm water or
leaves it to stand for a while until it reaches room temperature
• Continuous-feeding formulas should be kept cold; however,
excessively cold formulas can reduce flow of digestive enzymes by
causing vasoconstriction and may cause cramps
132

Managing clogged feeding tubes
• To prevent clogged feeding tubes, flush liberally (at least 30 mL
water) before, between, and after each separate medication is
instilled, using 60-mL piston syringe
• Don not add medication to formula as combination could create
precipitate that clogs the tube
• If all efforts to unclog tube fail, tube need to be removed
133

Removing a Nasogastric Tube

Sample documentation
11/4/2019 1030 #8 Fr feeding tube inserted without difficulty through
R nare. Ascertained proper placement using auscultation of injected air
and aspiration of 20 mL gastric content, green in color, c pH=4. Tube
secured to nose. ------------------------------------------------------R. Fakhry, RN
137

Evaluation
• The goals established in the planning phase are evaluated according
to specific desired outcomes
• If the outcomes are not achieved, the nurse should explore the
reasons

Nutrition last (1).ppt

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