Which nursing action prevents gastric cramping and discomfort during a nasoenteric feeding

1Explaining the procedure to the patient

Nội dung chính

• Which interventions help decrease the risk of aspiration during feeding?
• Which nursing action is priority when intubating a patient with a feeding tube?
• Which assessments should be made for a patient receiving tube feedings?
• Which equipment would the nurse have available to intubate a patient with a feeding tube quizlet?

When a patient needs to be administered enteral feedings via nasoenteric tube, the nurse explains the procedure to the patient during the planning phase, not assessment. Examining the patient's abdomen, asking the patient about food allergies, and evaluating the patient's nutritional status takes place during assessment.

Assess area of skin to be used as puncture site

Explain procedure and purpose to patient and/or family

Check code on test strip vial

Clean puncture site with antiseptic solution

Gently squeeze fingertip until a drop of blood appears

Wick blood drop into test strip

Read results and document in medical record

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Terms in this set (53)

What are the 6 classes of nutrients?

carbohydrates, proteins, lipids, vitamins, minerals, water

carbohydrates

-classified as simple or complex
-90% ingested and made into glucose
-50-100

protein

-required for all body structures
-classified as complete or incomplete
-constant break down & replacement
-around 60 gram needed QD

fats

-insoluble in water and blood
-95% in the diet are triglycerides
-saturated fat: high cholesterol levels
-unsaturated fat: low cholesterol levels
-no > 20-35% of daily calorie intake

vitamins

-need in small amounts
-active in the form of coenzymes
-need for metabolism
-absorbed directly into the bloodstream

water soluble vitamins

B vitamins and vitamin C

Fat soluble vitamins

A, D, E, K

minerals

inorganic elements
-found in body in the form of salt (Na+Cl-)
-found with organic compounds (Fe++ in Hgb)

macrominerals

any of the minerals that people require daily in amounts over 100 mg
-Phosphate, sulfur, calcium, sodium, potassium, chloride, magnesium

microminerals

those that people require daily in amounts less than 100 mg
-iron, zinc, copper, selenium, manganese, iodine, flouride

water

-in every living cell
-50-60% of human body weight
-medium necessary for all body functions
-not stored in the body
-intake: 2000-3000 mL a day

How do you measure weight by rule of thumb

FEMALE:
100 pounds for the first 5 feet, then 5 pounds for every inch over

MALE:
106 pounds for the first 5 feet, then 6 pounds for every inch over

solution for loss of appetite

Give appealing food
Remove clutter/small portions

solution for Dysphagia

Rest prior to meals
Sit upright (45-90 degrees ideal)
Alternate solids/liquids

solution for voluntary food restrictions

asl preferences and be respectful

solution for depression (eating)

eat in social settings

solutions for reflux (GERD)

Avoid spicy, greasy, and acidic foods
Avoid coffee, tea, chocolate, mint, citrus
Do not eat before bedtime
Elevate head of bed 30 degrees

what is a full liquid diet

nectar thick or honey thick liquid

what is a soft food diet

pureed or mechanical soft

what is a modified diet

low residue, low sodium or heart-healthy

what are short term solutions for enteral nutrition

-Nasogastric tube
-Nasointestinal tube

what are long term solutions for enteral nutrition

Percutaneous Endoscopic Gastronomy (PEG) tube
-no general anesthesia required
-low profile gastrostomy device (LPGD) is an option

Jejunum (J) tube
-into jejunum
-used in patients with gastric problems

What is the administration technique for enteral feedings

CHECK FOR PLACEMENT: x-ray initially, pH paper ideally, CO2 sensor

CHECK FOR RESIDUAL: if > 250 mL, there is a possible aspiration risk

CHECK LEVEL OF PATIENT: > 45 degree angle ideal but no < 30 degrees

FLUSH WITH WATER: 30-50 mL before and after food and medications

solution for aspiration with enteral feedings

Sit upright (45-90 degrees ideal)
Check for placement

solution for tube removal with enteral feedings

Secure tube prior
Notify the prescriber (MD/DO/PA/NP)

solution for clogged tube with enteral feedings

Flush with warm water
Dissolve & crush medications

what are the reasons for total parenteral nutrition (TPN)?

-Bypass of the GI system for the purposes of nutrition
-Nutrition enters the body by an IV into a vein
-Indwelling catheter needed (normally: PICC line or central line)

SHORT TERM USE ONLY

what does TPN consist of?

is a hypertonic solution which consists of:
-carbohydrates
-protein
-fats
-minerals
-vitamins
-insulin

what are the nursing implications for TPN and PPN

Monitor electrolytes closely & glucose checks Q4-6hr

What is peripheral parenteral nutrition (PPN)?

Isotonic solution with a lesser concentration of nutrients

Normally to supplement PO intake

Must have a dedicated IV line

What are possible complications of TPN?

Insertion problems
Infections and sepsis
Metabolic alterations
Phlebitis
Hyperlipidemia
Liver and gallbladder disease
Fluid, electrolyte and acid-base imbalances

An obese patient is asking for guidance to lose weight. Which hypothesis and patient-centered outcome would be the most appropriate related to nutrition for the patient?
A) Impaired Self-Feeding resulting in obesity. Patient will identify factors related to obesity by the next clinic appointment.
B) Impaired Swallowing resulting in obesity. Patient will identify factors related to obesity.
C) Excess Food Intake resulting in obesity. Patient will identify factors related to obesity by the next clinic appointment.
D) Deficient Food Intake resulting in obesity. Patient will identify factors related to obesity by the next clinic appointment.

C

Which individuals would a nurse collaborate with in an attempt to obtain the best possible outcomes for a pediatric patient with anorexia and bulimia?
A) Patient and dietitian
B) Patient, dietitian, and psychologist
C) Patient, dietitian, psychologist, and case manager
D) Patient, dietitian, school principal, and speech therapist

C

The primary nurse is advocating for a patient with a nursing hypothesis of Impaired Self-Feeding. With whom would the nurse collaborate to provide a cost-effective assistive feeding device for the patient?
A) Case manager
B) Speech therapist
C) Unlicensed assistive personnel (UAP)
D) Registered dietitian

A

Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Impaired Swallowing?
A) Inadequate dietary intake
B) Sensory and motor deficits secondary to spinal cord injury
C) Residual effects of neurologic damage secondary to cerebrovascular accident
D) Inadequate absorption of nutrients

C

Which primary pathophysiologic process would the nurse conclude is occurring in a patient who has a hypothesis of Impaired Self-Feeding?
A) Inadequate dietary intake
B) Sensory and motor deficits secondary to spinal cord injury
C) Psychological disorder
D) Limited physical activity

B

An underweight patient is asking for guidance to gain muscle weight. Which hypothesis and patient-centered outcome would be the most appropriate related to nutrition for the patient?
A) Impaired Self-Feeding resulting in low body weight. Patient will identify factors related to nutritional consumption by the next clinic appointment.
B) Impaired Swallowing resulting in low body weight. Patient will identify factors related to nutrition.
C) Excess Food Intake resulting in low body weight. Patient will identify factors related to nutritional consumption by the next clinic appointment.
D) Deficient Food Intake resulting in low body weight. Patient will identify factors related to nutritional consumption by the next clinic appointment.

D

Which nursing intervention is a priority if a patient's puncture site continues to bleed or develops a hematoma after blood glucose monitoring?
A) applying pressure to the puncture site
B) notifying the health care provider immediately
C) administering insulin or carbohydrates as prescribed
D) following agency protocol for laboratory confirmation testing

A

The nurse is feeding a patient with dysphagia. Which patient position should be avoided to reduce the risk of aspiration?
A) supine
B) sitting in a chair
C) high fowler's position
D) chin tucked position

A

Which nursing step is priority in monitoring blood glucose?
A) identifying the patient by name and medical record number
B) instructing the patient to perform hand hygiene with soap and warm water
C) comparing the glucose meter reading with any previous blood glucose levels
D) determining if the patient adequately performs glucose monitoring at home

A

Which action would the nurse implement when feeding a patient who is prescribed aspiration precautions? Select all that apply.
A) telling the patient to open his or her mouth
B) encouraging the patient to feel the food in his or her mouth
C) asking the patient to cough to clear the airway
D) rushing the patient to finish the meal as soon as possible
E) teaching the patient to raise his or her tongue to the roof of the mouth when eating

A, B, C, E

Which nursing action is appropriate when providing care to a patient who is prescribed intermittent tube feedings?
A) obtaining an xray film after each feeding
B) monitoring tube placement every 4-6 hours
C) checking tube placement prior to each feeding
D) flushing the tube with 15 mL of water to avoid clogging

C

Which nursing action supports safety guidelines that are essential when providing care to a patient who is receiving a tube feeding?
A) using surgical aseptic technique
B) placing the head of the patient's bed at 90 degrees
C) allowing the open formula system to hang for no more than 8 hours
D) adding food coloring to enteral nutrition to decrease the risk of hypertension

C

Which nursing action is appropriate when advancing the rate of a continuous tube feeding?
A) infusing a bolus of formula over 20-30 minutes
B) advancing the rate by 60-110mL/hr with every feeding
C) increasing the volume of formula by 50mL/hr every 8 to 12 hours
D) programming the infusion pump at 10-40mL/hr for the initial feeding

D

Which nursing action is appropriate when observing a patient for dysphagia during an aspiration risk assessment?
A) eliciting a gag reflex
B) measuring the patient's oxygen saturation
C) performing a nutrition screening on the patient
D) observing the patient eat various consistencies of food

D

Which nursing action promotes safety of a patient who is prescribed continuous enteral feeding?
A) using an infusion pump
B) auscultating for tube placement
C) placing the patient in supine position
D) sing surgical technique when providing patient care

A

The nurse is providing care to a patient who is prescribed intermittent enteral feedings. Prior to the scheduled feeding, the nurse notes a gastric residual volume (GRV) of 260mL. Which nursing action is the priority?
A) rechecking the GRV in 1 hour
B) consulting with the patient's dietician
C) placing the patient in a side-lying position
D) discarding the GRV and administering the scheduled feeding

A

-the nurse should withhold the feeding and recheck the GRV in an hour
-the GRV should be returned and the feeding held; discarding the GRV can cause fluid and electrolyte imbalances

Which nursing action prevents gastric cramping and discomfort during a nasoenteric feeding?
A) checking for the expiration date of the formula
B) warming the patient's formula to room temperature
C) implementing hand hygiene prior to administering formula
D) identifying the patient using 2 identifiers prior to administering the formula

B

Which patient is at greatest risk of experiencing inadequate nutrition?
A) A 55 year old obese man recently diagnosed with diabetes mellitus
B) a recently widowed 76 year old woman recovering from a mild stroke
C) a 22 year old mother with a 3 year old toddler who had tonsillectomy surgery
D) a 46 year old man recovering at home after coronary artery bypass surgery

B

A 45 year old patient has been put on a low-residue diet postoperatively. Which food should be avoided in the patient's diet?
A) pastas
B) casseroles
C) steamed vegetables
D) canned cooked vegetables

C

low residue includes low fiber foods like pasta, casseroles, moist tender meats, and canned and cooked fruits and vegetables-steamed vegetables contain high fiber

Which vitamin is fat-soluble and is stored in the adipose tissue of the body? Select all that apply.
A) vitamin A
B) vitamin B
C) vitamin C
D) vitamin D
E) vitamin E

A, D, E

A postoperative patient refuses to eat and complains of loss of appetite. Which intervention would the nurse perform to improve the patient's appetite?
A) offer smaller and more frequent meals
B) ensure that the patient eats alone
C) provide a low fiber diet
D) instruct the patient to skip breakfast

A

The nurse has a new prescription to monitor blood glucose on a patient, so the nurse provides information about the procedure and its purpose to the patient before taking the first measurement. Which phase of the nursing process is represented?
A) planning
B) evaluation
C) assessment
D) implementation

A

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Which interventions help decrease the risk of aspiration during feeding?

Suctioning reduces the volume of oropharyngeal secretions and reduces aspiration risk.

Which nursing action is priority when intubating a patient with a feeding tube?

The nurse is intubating a patient with a feeding tube. In which order should the nurse perform the following actions? Anchor the tube to the patient's nose.

Which assessments should be made for a patient receiving tube feedings?

Objective assessments for patients with enteral tubes include assessing skin integrity, tube placement, gastrointestinal function, and for signs of complications: Assess the tube insertion site daily for signs of pressure injury and skin breakdown. Cleanse and protect the area as indicated.

Which equipment would the nurse have available to intubate a patient with a feeding tube quizlet?

The nurse should have a towel, stethoscope, and water-soluble lubricant available during the insertion, or intubation, of a feeding tube.

Which nursing action prevents gastric cramping and discomfort during a Nasoenteric?

Which nursing action is appropriate when administering an enteral feeding to a patient?

Which nursing action is essential when providing continuous internal feeding?

What safety measures have to be maintained while the patient is receiving an enteral tube feeding?