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  1. 1. METABOLISM<br />Ma. Tosca Cybil A. Torres, RN, MAN<br />MTCAT &apos;09<br />
  2. 2. Definition of Terms:<br />Metabolism- all biochemical reactions within the body.<br />Basal Metabolic rate- energy requirement of an awake person at rest<br />Energy needed at a person’s lowest level of cellular function<br />Nutrients- any ingested chemical that is used for growth, repair and maintenance of the body.<br />Catabolism- breakdown of complex structures into simpler forms.<br />Anabolism- process by which simpler molecules combine to build more complex structures.<br />MTCAT &apos;09<br />
  3. 3. Gastrointestinal System<br />MTCAT &apos;09<br />
  4. 4. Gastrointestinal Tract<br />Upper GIT<br /><ul><li>consists of structures that aid in the ingestion and digestion of food
  5. 5. includes the mouth, esophagus, stomach, duodenum</li></ul> Hypothalamus – satiety center<br /><ul><li> is responsible for notifying the body that it is satisfied or has received sufficient food</li></ul>Lower GIT<br /><ul><li>consists of the small and large intestines
  6. 6. digestion is completed in the small intestine , and most nutrients are absorbed in this part of the GIT
  7. 7. the large intestine serves primarily to absorb water and electrolytes and to eliminate the waste products of digestion through the feces</li></ul>MTCAT &apos;09<br />
  8. 8. Gastrointestinal Tract<br />Mouth<br />Salivation <br /><ul><li>the “thought” of food initiates saliva production</li></ul> a.) serous secretions  contain ptyalin for starch digestion –<br /> produced by parotid and submaxillary glands<br /> b.) mucous secretions - for lubrication of food – produced by the <br />buccal, sublingual and submaxillary glands<br />Mastication<br /><ul><li>chewing of food
  9. 9. teeth - for initial breakdown of food to small particles
  10. 10. it helps prevent excoriation of the lining of the tract and increase rate of digestion</li></ul>Major Structures in the Mouth<br /><ul><li>teeth – to grind the food
  11. 11. salivary glands – moisten food and mucous membranes and begin carbohydrate digestion
  12. 12. tongue – to push the food to the pharynx to initiate swallowing</li></ul>MTCAT &apos;09<br />
  13. 13. Gastrointestinal Tract<br />Esophagus<br /><ul><li>is a hollow tube, the upper 1/3 is composed of skeletal muscles, the rest is smooth muscle
  14. 14. lined with mucous membrane – secretes mucoid substance for protection
  15. 15. the bolus of food arrives at the cardiac sphincter of the stomach w/in 5-10 secs. after ingestion
  16. 16. the lower esophageal sphincter (LES) prevents reflux of food in the stomach back into the lower esophagus</li></ul>Swallowing (deglutition)<br />3 phases:<br />1.) tongue forces the bolus of food into the pharynx<br />2.) the food moves into the upper esophagus<br />3.) the food moves down into the stomach<br />* Food is prevented from passing into the trachea by closing of the trachea (epiglottis) and the opening of the esophagus<br />MTCAT &apos;09<br />
  17. 17. MTCAT &apos;09<br />
  18. 18. MTCAT &apos;09<br />
  19. 19. Gastrointestinal Tract<br />Stomach<br /><ul><li> made up of 5 layers of smooth muscle</li></ul>2 types of contractions:<br />1.) tonus contractions – continuous contractions<br />2.) rhythmic contractions – may be slow ( q2-3 mins.) or fast –<br /> responsible for the mixing of food and peristaltic movement<br />Vagus nerve – supplies the nervous stimulation for the stomach <br /> - has both symphathetic and parasymphatetic fibers<br /><ul><li>movement of food through the stomach and intestines is by peristalsis the alternate contraction and relaxation of the muscle fibers that propels the food in a wave-like motion</li></ul>chyme – food in the stomach<br /> - is pumped through the pyloric sphincter into the duodenum<br />MTCAT &apos;09<br />
  20. 20. MTCAT &apos;09<br />
  21. 21. MTCAT &apos;09<br />
  22. 22. Gastrointestinal Tract<br />Digestive Function of the Stomach:<br />Pepsin – needed for protein digestion<br />HCL acid – aids in pre-digestion of food<br />MTCAT &apos;09<br />
  23. 23. Gastrointestinal Tract<br />Intestines<br />Small Intestine<br /><ul><li>2.5 cm. (1 inch) wide and 6 meters (20 feet) long – fills most of the abdomen</li></ul> 3 parts :<br />a.) duodenum – which connects to the stomach (10 inches)<br />b.) jejunum – middle portion (8 feet long)<br />c.) ileum – with connects to the large intestine (12 feet long)<br />Large Intestine<br /><ul><li>6 cm. (2 ½ in.) wide and 1.5 meters (5 feet long)</li></ul> 3 parts :<br />a.) cecum – which connects to the small intestines<br />b.) colon – 4 parts (ascending, transverse, descending, sigmoid colon)<br />c.) rectum – 17-20 cm. (7-8 inches) long,  anal canal<br />MTCAT &apos;09<br />
  24. 24. MTCAT &apos;09<br />
  25. 25. Gastrointestinal Tract<br /><ul><li>ileocecal valve– prevents backward flow of fecal contents from the large intestine to the small intestine
  26. 26. vermiform appendix – has no function , near the ileocecal valve
  27. 27. anus – anal opening, is controlled by a smooth muscle internal sphincter and a striated muscle external sphincter
  28. 28. chymeis propelled toward the anus by peristalsis, also mixes the intestinal contents
  29. 29. in the colon, the feces is pushed forward by mass movements – stimulated by gastrocolic reflexes initiated when food enters the duodenum from the stomach
  30. 30. Defecation reflex
  31. 31. when feces enter the rectum and cause distention of wall of the rectum  send impulses to the sacral segment of the spinal cord – then back to the colon, sigmoid and rectum  initiate relaxation of the internal anal sphincter  relaxation or contraction of external anal sphincter (voluntary control)</li></ul>MTCAT &apos;09<br />
  32. 32. Gastrointestinal Tract<br />Secretion and Digestion<br /><ul><li>major portion of digestion occurs in the small intestines by the action of pancreatic and intestinal secretions (enzymes) and bile </li></ul>a.) Carbohydrate digestion<br /> start in the mouth Ptyalin – breakdown polysaccharides to <br /> disaccharides<br /> intestinal enzymes (maltase, lactase, sucrase) <br /> breakdown disaccharides to monosaccharides (glucose, galactose<br /> fructose) <br />b.) Protein digestion<br /> - start in the stomach pepsin – breakdown of proteins to polypeptides<br /> - small intestines trypsin – breakdown of polypeptides into peptides and<br /> amino acids<br />c.) Fat digestion<br /> - fats require emulsification into small droplets before it can be broken<br /> down into glycerol and fatty acids<br />Bile – from liver; emulsify fats so that it could be broken down<br />pancreatic lipase  breakdown fats into glycerol and fatty acids<br />MTCAT &apos;09<br />
  33. 33. Gastrointestinal Tract<br />Absorption<br /><ul><li>the intestinal wall has many folds which are covered by fingerlike projections called (villi)  increase the absorptive area of the small intestines
  34. 34. in the center of the villi are capillaries, veins, small arteries for absorption of nutrients into the blood vessel system
  35. 35. 90% of absorption occurs within the small intestines by active transport or diffusion
  36. 36. amino acids, monosaccharides, Na+, Ca++ are transported by active transport w/ the expenditure or use of energy
  37. 37. other nutrients, fatty acids and H2O – diffuse passively across the cell membrane
  38. 38. reabsorption of H2O, electrolytes and bile occurs mainly in the ascending colon</li></ul>MTCAT &apos;09<br />
  39. 39. MTCAT &apos;09<br />
  40. 40. Gastrointestinal Tract<br />GIT role in Fluid and Electrolytes Balance<br /><ul><li>GIT secretions contain electrolytes
  41. 41. severe fluid and electrolyte imbalance may occur with excessive losses of gastrointestinal fluids</li></ul> Ex. 1.) Na+ and K+ deficits : vomiting, diarrhea, gastric suctioning,<br /> intestinal fistula<br /> 2.) Ca++ & Mg++ deficits: malnutrition, malabsorption, intestinal fistula<br /> 3.) Metabolic alkalosis : loss of gastric acid by suctioning or persistent<br /> vomiting<br /> 4.) Metabolic acidosis : loss of bicarbonate-rich intestinal secretions<br /> by severe diarrhea or fistula<br />Other functions of the GIT<br /><ul><li>the GIT supports bacterial growth and has a role in antibody formation
  42. 42. intestinal bacteria synthesize Vit. K  required for production of clotting factors II (Prothrombin), VII, IX,X</li></ul>MTCAT &apos;09<br />
  43. 43. PHYSIOLOGY OF DIGESTION AND ABSORPTION<br />Digestion: physical and chemical breakdown of food into absorptive substances.<br />Initiated in the mouth where food mixes with saliva and starch is broken down.<br />Food then passes into the esophagus where it is propelled into the stomach.<br />In the stomach, food is processed by gastric secretions into a substance called chyme.<br />
  44. 44. In the small intestine, carbohydrates are hydrolyzed to monosaccharides, fats to glycerol, and fatty acids and proteins to amino acids to complete the digestive process.<br />When chyme enters the duodenum, mucus is secreted to neutralize hydrochloric acid; in response to release of secretin, pacreas releases bicarbonate to neutralize acid chyme.<br />Cholecystokinin and pancreozymin (CCK- PZ) are also produced by duodenal mucosa; stimulate contraction of the gall bladder along with relaxation of the sphincter of Oddi (to allow bile to flow from the common bile duct into the duodenum, and stimulate release of pancreatic enzymes.<br />
  45. 45. NUTRITION<br />Nutrition is the sum of all interactions between an organism and the food it consumes.<br />MTCAT &apos;09<br />
  46. 46. 6 MAJOR CLASSES OF NUTRIENTS <br /> WATER 2.5 L Macronutrient<br /> CHO 125-175 g.<br /> LIPIDS 80-100 g.<br /> PROTEIN 44-60 g.<br /> MINERALS 0.05-3,300 mg. Micronutrient<br /> VITAMINS 0.002-60 mg.<br />
  47. 47. WATER<br /><ul><li>Composes 60% - 70% of TBW
  48. 48. Lean people contain more water than obese people
  49. 49. *per ml/kg/day Behrman, Vaughan VC: Nelson’s Textbook of Pediatrics, 1987</li></li></ul><li>Essential Nutrients <br />CARBOHYDRATES (CHO) <br />Types: <br />Sugars <br />simplest of all CHOs<br />Water soluble<br />Produced naturally by plants and animals <br />May be monosaccharide or disaccharide<br />Starches<br />Insoluble, nonsweet forms of CHO<br />Polysaccharide <br />Nearly all starches come form plants <br />Fiber <br />Complex CHO from plants <br />Cannot be digested by humans but supplies roughage or bulk to the diet <br />MTCAT &apos;09<br />
  50. 50. Digestion (CHO)<br />Desired end product of CHO are monosaccharides (Glucose, fructose, galactose) <br />Major enzymes: <br />Ptyalin (salivary amylase) <br />Pancreatic amylase<br />MTCAT &apos;09<br />
  51. 51. Metabolism (CHO)<br />Storage and conversion <br />Stored either as glycogen or fat <br />Glycogen <br />Large polymer of glucose <br />Process of glycogen formation----GLYCOGENESIS<br />Stored mostly in the liver and skeletal muscles<br />Glucose that cannot be stored as glycogen are stored as fat <br />MTCAT &apos;09<br />
  52. 52. Glycogenolysis<br />Breakdown of glycogen to reform glucose for use of cells <br />Activated by GLUCAGON and EPINEPHRINE <br />When blood glucose concentration falls alpha cells (pancreas) secrete glucagon  stimulates glycogenolysis mainly in the liverliver delivers glucose to the bloodstream elevate blood glucose level <br />SNS stimulated  adrenal medulla releases epinephrine stimulates glycogenolysis in both the liver and muscle cells release energy needed during sympathetic stimulation <br />MTCAT &apos;09<br />
  53. 53. Gluconeogenesis<br />Process of forming of glucose from protein (amino acids) and fat reserves<br />Occurs in the liver <br />Only up to 60% of CHON can be coverted into glucose<br />MTCAT &apos;09<br />
  54. 54. Essential Nutrients <br />PROTEIN (CHON) <br />Organic substances composed of amino acids <br />Amino acids are the most important components of protein. Essential for synthesis of body tissue in growth, maintenance and repair.<br />It is responsible for muscle contraction and motility of cilia and flagella.<br />Yields 4 kcal/g<br />RDA is 44 to 60 g depending on age and sex.<br />Multiply your wt. in lbs x 0.37 = e RDA<br />Category:<br />Essential amino acids <br />Those that cannot be manufactured in the body and must be supplied as part of the diet <br /> Non essential amino acids<br />Can be manufactured in the body <br />MTCAT &apos;09<br />
  55. 55. Digestion (CHON)<br />start in the stomach pepsin – breakdown of proteins to polypeptides<br /> small intestines trypsin – breakdown of polypeptides into peptides and amino acids<br />MTCAT &apos;09<br />
  56. 56. Metabolism (CHON)<br />Storage <br />Absorbed by active transport through the small intestine into the portal blood circulation <br />CHON is “stored” as body tissue<br />Body cannot actually store CHON for future use. <br />MTCAT &apos;09<br />
  57. 57. Essential Nutrients <br />LIPIDS <br />Organic substances that are greasy and insoluble in water but soluble in alcohol or ether. <br />Fats are lipids that are solid in room temperature<br />Oil are lipids that are liquid in room temperature<br />Fatty acids basic structural unit of most lipids<br />MTCAT &apos;09<br />
  58. 58. Digestion (LIPIDS)<br />Starts in the stomach digested mostly in the small intestine by bile, pancreatic lipase and enteric lipaseEnd product are glycerol, fatty acids, and cholesterol reassembled in the intestinal cells into triglycerides and cholesterol esters (cholesterol w/ fatty acids) converted by the small intestine and liver to LIPOPROTEINS for transportation<br />MTCAT &apos;09<br />
  59. 59. Lipoproteins <br />Lipoproteins- made up of various lipids and a protein <br />Classification <br />High-density lipoproteins (HDL) contains the highest concentrations of CHON (50%)<br />Low-density lipoprotein (LDL) contains very high concentration of cholesterol <br />Very-low-density lipoprotein (VLDL)contains little protein but high concentrations of triglycerides and moderate concentrations of phospholipids and cholesterol <br />MTCAT &apos;09<br />
  60. 60. Storage (LIPIDS)<br />Store in 2 major tissues:<br />Adipose tissue (fat depot) <br />Stores triglycerides until needed for energy<br />Insulator<br />Liver <br />MTCAT &apos;09<br />
  61. 61. MICRONUTRIENTS<br />Vitamin<br />An organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze metabolic processes <br /><ul><li>Abundant in fresh foods eaten as soon as possible after harvest</li></ul>MTCAT &apos;09<br />
  62. 62. Vitamin classification: <br />Water-soluble vitamins<br />Cannot be stored in the body body needs daily supplementation <br />Vitamin C, Vitamin B-complex<br />Fat-soluble vitamins <br />Can be stored in the body vit E and K with limitation <br />Daily supplementation is not absolutely necessary <br />Vitamin A, D, E, K <br />MTCAT &apos;09<br />
  63. 63. Minerals<br />Inorganic elements essential to the body because of their role as catalysts in biochemical reactions.<br />CLASSIFICATION<br />Macrominerals. When the daily requirement is 100 mg or more<br />Microminerals. When the daily requirement is less than 100 mg.<br />MTCAT &apos;09<br />
  64. 64. FOUNDATIONS OF AN ADEQUATE DIET<br />Food Guide Pyramid - 1992<br />Recommended Daily Allowance – 1943 – level of intake of essential nutrients considered to be adequate to meet the nutritional needs of healthy people<br />Other Dietary Guidelines (1990)<br />Eat a variety of food<br />Choose a diet low in fat, saturated fat and cholesterol.<br />Choose a diet with plenty of vegetables, fruits and grain products.<br />Use sugar in moderation.<br />Use salt in moderation.<br />If you drink, do so in moderation.<br />
  65. 65. The Food Pyramid<br />GRAINS<br />VEGETABLES<br />FRUITS<br />OILS<br />MILK<br />MEAT & BEANS<br />
  66. 66.
  67. 67. DEVELOPMENTAL VARIABLES IN NUTRITION<br /><ul><li>Infant. Needs a high amount of fluid; High energy requirement</li></ul> Breast-fed Infants. Breast milk as the major source of nutrients for the first 4 to 6 months.(80-100ml/kg of body weight)<br /><ul><li>Vit. C supplement can be given at 1 to 2 mos.
  68. 68. Iron can be given after 4 mos.
  69. 69. Toddlers and Preschoolers
  70. 70. Growth rate slows during toddler years (1 to 3)
  71. 71. Needs fewer calories but an increase amount of protein in relation to body weight.
  72. 72. Should also receive four servings of fruits and veggies.</li></li></ul><li>School age children <br /> Grow at slower and steadier rate, with a gradual decline in energy requirements per unit of body weight.<br />Adolescence<br />Increase caloric need, as well as the protein and calcium need for bone growth<br />Nutritional deficiencies occur. – fad diets.<br />Young and Middle adult<br />Needs nutrient for energy, maintenance and repair.<br />Pregnancy. Total weight gain of 10-15 kg. (22 to 35 lbs) is recommended<br />Calcium Intake of 1200 mg/day esp. in the 3rd trimester<br />Iron 30 mg/day<br />
  73. 73. MTCAT &apos;09<br />FACTORS INFLUENCING DIETARY PATTERNS<br /><ul><li>Health Status</li></ul>“ a good appetite is a sign of health.”<br /><ul><li>Culture and Religion
  74. 74. Socioeconomic Status
  75. 75. Personal Preference
  76. 76. Psychological Factor
  77. 77. Alcohol and drugs
  78. 78. Misinformation and food fads.</li></li></ul><li>VARIABLES AFFECTING AN INDIVIDUAL’S CALORIE NEED<br />
  79. 79. MTCAT &apos;09<br />
  80. 80. MTCAT &apos;09<br />
  81. 81. MTCAT &apos;09<br />
  82. 82. MTCAT &apos;09<br />
  83. 83. Assessing Nutritional Status“ABCD Approach”<br />Anthropometric measurement<br />Biochemical Data<br />Clinical signs<br />Dietary History<br />
  84. 84. ANTHROPOMETRY<br />System of measurement of the size and make up of the body and specific body parts.<br />INCLUDE:<br />Weight*<br />Height<br />BMI = wt. in kg/ (ht in meter) 2<br />20-25% Normal<br />27.5-30% Mild Obesity<br />30-40% Moderate<br />Above 40% Severe<br />Wrist circumference<br />Mid upper arm circumference (MAC)<br />Triceps skin fold (TSF)<br />
  85. 85. Height and weight should be obtained on hospital admission.<br />Weigh daily.<br />Wrist measurement is used to estimate the client’s body frame.<br />Height in cm divided by wrist circumference= frame size<br />N value= &gt;10.4 to 10.9cm (small), 10.4 – 9.6 (Medium),&lt; 9.6 (large)<br />
  86. 86. MAC determines muscle wasting.<br />Measured at the mid point of the arm.<br />N values = 28.3 men, 28.5 women<br />Skinfold measurement determine fat content of subcutaneous tissue.<br />N values = 12.5 cm men, 18 cm women<br />Other areas measured biceps, scapula and abdominal muscles<br />
  87. 87. Biochemical Data<br />Hgb & Hct indices<br />Serum albumin<br />Transferrin (blood protein that binds with iron)<br />Total lymphocyte count<br />Nitrogen balance<br />Creatinine excretion<br />
  88. 88. Clinical Signs<br />Clinical Signs Indicative of Nutritional Status<br />Hair- dull, brittle, depigmented, easily plucked<br />Face- skin dark over cheeks and under eyes, skin flaky, face swollen<br />Eyes- Eye membranes pale, dry (xeropthalmia), Bitot’s spots, increased vascularity, cornea, soft (kerotomalcia)<br />Lips- swollen and puffy (cheilosis), angular lesions at corners of mouth (angular fissures)<br />Tongue- smooth appearance, swollen, beefy red, sores, atrophic papillae<br />
  89. 89. Clinical signs<br />Teeth- Cavities, mottled appearance (fluorosis), malpositioned<br />Gums-spongy, bleed easily, marginal redness, recession<br />Glands- thyroid enlargement (simple goiter)<br />Skin- rough, dry, flaky, swollen, pale, pigmented, lack of fat under skin<br />Nails- spoon shaped, ridged<br />Skeleton- poor posture, beading of ribs, bowed legs or knock legs<br />Muscles- flaccid, poor tone, wasted, underdeveloped<br />Extremities- weak and tender, presence of edema<br />Abdomen- swollen<br />Nervous system- decrease in or loss of ankle and knee reflexes<br />
  90. 90. Dietary History<br /> It considers the quantity and quality of food intake and also frequency of consumption of certain food items in order to determine the current or customary intake of nutrients.<br />
  91. 91. Methods<br />Food Record<br /><ul><li>Used most often in nutritional status studies.
  92. 92. The client is asked to keep a record of food actually consumed over a period of time, varying from 3 to 7 days.
  93. 93. It appears to be fairly accurate.</li></ul>24- hour Recall<br /><ul><li>Recall of food intake over a 24- hour period.
  94. 94. The subject is asked to recall all food eaten during the previous day and to estimate the quantities of food consumed.
  95. 95. Information obtained by this method is not always representative of usual food intake.</li></li></ul><li>CLIENTS AT RISK FOR NUTRITIONAL PROBLEMS<br />Obesity– condition in which there is 20% increase above ideal body weight.<br />Anorexia nervosa – self-imposed starvation<br />Bulimia – binge-purge syndrome<br />Post op clients<br />Immobilized client<br />Cancer and radiotherapy<br />
  96. 96. Food and Fluid Intake regulating Mechanism<br /><ul><li>Thirst – triggered by loss of fluid of more than 2 %
  97. 97. Hunger – triggered by low blood glucose level
  98. 98. Appetite – sight, smell, and thought of food
  99. 99. Satiety – triggered by gastric distention</li></li></ul><li>Regulation of Food Intake<br />Hypothalamus – regulation of feeding and satiety<br />Ventromedial nucleus – satiety center (stimulation results in cessation of appetite)<br />Ventrolateral area – initiate feeding behavior and has termed feeder center<br />Blood glucose concentration – is thought to be a major regulator of activities of the center.<br />
  100. 100. Diagnosing<br />Altered nutrition: more than body requirements<br />Altered nutrition: less than body requirements<br />Activity intolerance<br />Constipation <br />Diarrhea<br />Knowledge deficit<br />Self-esteem disturbance <br />Potential for impaired skin integrity<br />MTCAT &apos;09<br />
  101. 101. IMPLEMENTATION<br />Stimulating Appetite(depending on the medical condition)<br />Serve food in pleasant and attractive manner<br />Mouth care<br />Position comfortably<br />Promote comfort<br />Relieve pain<br />Adequate ventilation and humidity<br />Remove unsightly articles<br />Check very tight or very loose clothing<br />Remember that color affects appetite to eat.<br />Environment – curtain the unit of patients on NPO<br />Diet Therapist<br />Special Diets<br />Hospital Diets<br />Diet therapy in disease management<br />
  102. 102.
  103. 103.
  104. 104.
  105. 105.
  106. 106. Alternative Feeding:<br />Enteralhyperalimentation- delivery of nutrients directly to the GI tract.<br />Short- term- esophagostomy; nasogastric tube<br />Long- term- gastrostomy; jejunostomy<br />Indications of NGT:<br />Gavage- to deliver nutrients and medication; for feeding purposes<br />Lavage- to irrigate the stomach<br />Decompression- to remove stomach contents or air<br />MTCAT &apos;09<br />
  107. 107. MTCAT &apos;09<br />
  108. 108. SKILLS: NGT Insertion<br />PURPOSES OF NGT INSERTION:<br />To provide feeding <br /> (gastric gavage)<br />To irrigate stomach <br /> ( gastric lavage)<br />For decompression (drainage of gastric content)<br />To administer medication.<br />
  109. 109. INSERTION<br />Inform the patient and explain the procedure.<br />Place in high- Fowler’s<br />Measure length of NGT to be inserted (NEX technique) = 50 cm.<br />Lubricate tube with water soluble lubricant. To reduce friction. Do not use oil.<br />Hyperextend the neck, gently advance the tube toward the nasopharynx.<br />Tilt the patient’s head forward once the tube reaches the oropharynx, and ask to swallow as the tube is advanced.<br />Secure the NGT by taping it to the bridge of the client’s nose, after checking the position of the tube placement.<br />
  110. 110. Administering Tube Feeding<br /><ul><li>Assist the client to a semi-Fowler’s position in bed or sitting position in a chair, or slightly elevated right side-lying position.
  111. 111. Assess tube placement and patency.
  112. 112. Introduce 5-20ml of air into the NGT and auscultate at the epigastric area, gurgling of sound is heard.
  113. 113. Aspirate gastric content, which is yellowish or greenish in color.
  114. 114. Immense tip of tube in water, no bubbles should be produced.
  115. 115. Measure the pH of the aspirated fluid which should be acidic.
  116. 116. Ask the client to speak or hum
  117. 117. Observe the client for coughing or choking.</li></ul>The most effective method of checking the NGT is radiograph verification then, checking pH of aspirated gastric content.<br />
  118. 118. <ul><li>Assess residual feeding contents. to assess absorption of the last feeding, if 50ml or more, verify if the feeding will be given.
  119. 119. Introduce feeding slowly. To prevent flatulence, crampy pain and or reflex vomiting.
  120. 120. Height of feeding is 12 inches above the tube’s point of insertion into the client. This allows slow introduction of feeding.
  121. 121. Instill 60 ml of water into the NGT after feeding. To cleanse the lumen of the tube.
  122. 122. Clamp the NGT before all of the water is instilled. To prevent entry of air into the stomach.
  123. 123. Ask client to remain in Fowler’s position or in slightly elevated right lateral position for at least 30 min. To prevent potential aspiration of feeding.
  124. 124. Do after care of equipment.
  125. 125. Make relevant documentation.</li></li></ul><li>Gastrostomy<br /> A gastrostomy is a surgical procedure in which an opening is created into the stomach for the purpose of administering foods and fluids via a feeding tube. <br />
  126. 126. Meeting Nutritional Needs<br /><ul><li>The first fluid nourishment is administered soon after surgery and usually consists of tap water and 10% dextrose. At first, only 30 to 60 mL (1 to 2 oz) is given at one time, but the amount administered is increased gradually. By the second day, 180 to 240 mL (6 to 8 oz) may be given at one time, provided it is tolerated and no leakage of fluid occurs around the tube. Water and enteral feeding can be infused after 24 hours for a permanent gastrostomy.
  127. 127. Blen foods can be added gradually to clear liquids until a full diet is achieved. Powdered feedings that are easily liquefied are commercially available. </li></li></ul><li>NURSING CARE OF CLIENTS WITH GASTROSTOMY <br />Providing Tube Care and Preventing Infection<br />Providing Skin Care<br />Enhancing Body Image<br />Monitoring and Managing Potential Complications<br />
  128. 128. Teaching Patients Self-Care<br />Demonstration of the tube feeding begins by showing the patient how to check for residual gastric contents before the feeding.<br />All feedings are given at room temperature or near body temperature.<br />For a bolus feeding, the nurse shows the patient how to introduce the liquid into the catheter by using a funnel or the barrel of a syringe. The receptacle is tilted to allow air to escape while the liquid is being instilled initially. As the funnel or syringe fills with liquid, the feeding is allowed to flow into the stomach by gravity by holding the barrel or syringe perpendicular to the abdomen. Raising or lowering the receptacle to no higher than 45 cm (18 in) above the abdominal wall regulates the rate of flow.<br />
  129. 129. Teaching Patients Self-Care<br />A bolus feeding of 300 to 500 mL usually is given for each meal and requires 10 to 15 minutes to complete. The amount is often determined by the patient&apos;s reaction. If the patient feels full, it may be desirable to give smaller amounts more frequently.<br />The patient and caregiver must understand that keeping the head of the bed elevated a minimum of 45 degrees for at least 1 hour after feeding facilitates digestion and decreases the risk of aspiration. Any obstruction requires that the feeding be stopped and the physician notified.<br />
  130. 130.
  131. 131. Teaching Patients Self-Care<br />The patient or caregiver is instructed to flush the tube with 30 to 50 mL of water after each bolus or medication administration and to also flush the tube daily to keep it patent.<br />The patient and caregiver are made aware that the tube is marked at skin level to provide the patient with a baseline for later comparison. They are advised to monitor the tube&apos;s length and to notify the physician or home care nurse if the segment of the tube outside the body becomes shorter or longer.<br />
  132. 132. Hyperalimentation (total parenteral nutrition)- method of giving highly concentrated solutions intravenously to maintain a patient’s nutritional balance when oral or enteral nutrition is not possible<br />Nursing Managements:<br /><ul><li>Filter is used in the IV tubing to trap bacteria
  133. 133. Solution and administration equipment should be changed every 24 hours
  134. 134. Dressing changes every 48-72 hrs with antibiotic ointment to catheter insertion
  135. 135. Medication is never administered in a TPN line
  136. 136. Observe for complications
  137. 137. Infection
  138. 138. Venous thrombosis
  139. 139. Hyperglycemia</li></ul>MTCAT &apos;09<br />
  140. 140. Evaluation <br />MTCAT &apos;09<br />