Enternal nutrition, ATI Nurse Logic-Priority setting frameworks beginning test

Enteral Nutrition is…
Alternate form of feeding a client, & Given when client unable to ingest foods

Enteral Access obtained by:
-Nasogastric tubes
-Nasointestinal (nasoenteric) tubes
-Gastrostomy tubes
-Jejunostomy tubes

Nasogastric (NG) Tubes
-Inserted through nostril, advanced down through nasopharynx, and into the alimentary tract
-For short term therapy (feedings)
-Clients must have adequate stomach emptying
-Not advised for feedings if gag reflex absent due to risk of accidental placement in lungs

Levin tube:
single lumen; used to remove gastric contents via intermittent suction or to provide tube feedings.

Salem sump tube:
double lumen with air vent; used for decompression with constant suction

Purpose for NG Tube
-Tube feedings and medication administration
-For stomach lavage following poisoning or overdose
-For prevention of N/V & gastric distention postoperatively
-To obtain stomach contents for diagnostic analysis

Nasointestinal Tubes
-Inserted through a nostril and goes down into the upper small intestine
-Longer than NG tube
-Used when clients are at risk for aspiration

Nasointestinal Tubes used for Clients who are at risk of aspiration include:
-Decreased level of consciousness
-Poor cough or gag reflexes
-Inability to participate in the procedure
-Restlessness or agitation

Gastrostomy Tubes
-Surgically inserted by surgeon through surgery or by laparoscopy
-Through abdominal wall into stomach
-Used for long term nutritional support (More than 6-8 weeks)
-surgical asepsis required until healed

Jejunostomy Tubes
-Surgically implanted
-Through abdominal wall into jejunum
-Used for long term nutritional support

Daily Care of NG Tube:
-Inspect nostril for discharge or irritation
-Clean nostril and tube with moist cotton-tipped applicator
-Apply water soluble lubricant if nostril dry or encrusted
-Change tape as needed
-Frequent oral care; mouth breather possibly due to tube presence

check placement by:
-Aspirate gastric contents
-Measure pH
-Confirm tube length with insertion mark

Gastric contents tend to be
grassy-green, off-white, or tan.

Intestinal secretions usually have a
yellow or brownish-green color.

Gastric PH should be
1-4/5.

Intestinal PH is =
or > 6.

Respiratory PH
7 or >.

NG Tube Irrigation
-Assess placement before irrigation
-Irrigate every 4 hours to check placement and to maintain patency of tube
-Gently instill 30-50 mL of water or NS with irrigation syringe per agency policy

Enteral Feedings
-Can be administered intermittent or continuous
-Can be administered by open or closed system
-Keep HOB elevated with continuous feeds
-Elevate HOB to Fowler’s (30 degrees or higher)

Intermittent:
-300-500 ml several times daily.
-Administered over at least 30 minutes.
-should be no more than 120 ml increasing by 120 ml each feeding if tolerated until desired goal is reached

Bolus intermittent feedings
-given rapidly using a syringe.
-Not usually recommended but if tolerated may be used in long term situations.
-ONLY into stomach

Continuous feedings
-are administered over 24 hours using an infusion pump (kangaroo pump).
-Initially at 60ml/hour increasing by 20ml/hour if tolerated until goal reached
-Check residual every 4-6 hours.

Cyclic feedings:
continuous feeds less than 24 hours (12 to 16 hours/day).
-Generally given at night.
-Allows client to eat regular meals during day.

An open system
– has an open-top container or a syringe is used for administration
-no more than 8-12 hours of formula at a time.
-Bag/tubing change tubing every 24 hours.

Closed systems
have prefilled bottles of formula which must be spiked.
-They can hang safely for 48 hours provided that sterile technique is maintained.

Large residuals indicate
delayed gastric emptying and puts patient at risk for aspiration.

when feeding you should…
-Warm feedings to room temperature to prevent cramping and diarrhea
-Use feeding pump for cyclic or continuous feedings
-Keep HOB elevated
-Check expiration date of formula

Flush with 30-50mL after…
feeding complete

Most accurate method for checking tube placement is
x-ray

Most effective non-radiological method is
aspiration with pH measurement and content description

Assessment includes:
-Assess bowel sounds
-Placement of tube
-Abdominal distention
-Urine for sugar and acetone
-Hematocrit
-Urine specific gravity
-BUN
-Sodium level

Complications:
-Diarrhea
-Vomiting
-Constipation
-Tube displacement
-Delayed gastric emptying
-Fluid overload
-Aspiration
-Clogged tube

Medication Administration via G-tube or J-tube
-Make sure medication can be crushed or capsule opened
-Crush meds and dissolve in 15-30 mL water
-Check placement and residual prior to administration
-Assess bowel sounds
-Draw medication up into catheter tip syringe
-Administer medication into tube
-Flush tube with 30-50 mL water or NS
-clamp tube for 30-60 minutes depending on agency policy

Continuous suction is used with
double lumen tubes (Salem sump). Usually set at 60 – 120 mmHg or as prescribed by the HCP.

Intermittent suction regulators are generally used with
-single lumen tubes.
-Suction is applied for approximately 15 – 60 seconds followed by intervals of no suction.
-Suction is set at 80 – 100 mmHg or as prescribed by the HCP.

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse?
Diarrhea

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
A client who had abdominal surgery 10 days ago and reports feeling his incision pop

A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?
Creating meaningful social relationships

A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse?
Have the client position the head with the chin down while swallowing

A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider?
Digoxin 3.0ng/mL

A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?
Move the client to room near the nurses station

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
Place the infant in a supine position when sleeping

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?
Obtain an ECG

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
Place the client in the orthopneic position

A nurse is collecting data on four clients. Which of the following findings is the most urgent?
Warmth and pain in the calf

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client’s oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first?
Assist client to cough effectively

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?
Determine the mobility status of each patient

A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?
Platelets 95,000 mm3

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse’s station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first?
Check on the client

A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action?
Maintaining a patent airway

A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster?
Immediate

A nurse in a provider’s office has collected data on four clients. Which of the following clients should be the nurse’s priority concern?
A client who is having a nosebleed associated with hypertension

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit?
Check the heart rate and blood pressure

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?
Check the leg for warmth and edema

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?
Hypoxic

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse …

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