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36 Cards in this Set

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Nothing By Mouth

Diet As Tolerated
2. What are the various therapeutic diets that Hospitals provide? (x5)
1.regular (house),
2.clear liquid,
3. full liquid,
4. soft, and
5. diet as tolerated (DAT). (K. p. 1201)
2. Describe the following therapeutic diet and explain its rationale: Regular:
For hospitalized clients who do not have special needs.
A balanced diet that supplies metabolic requirements of the sedentary person (about 2,000 Kcal).
Difficult to digest foods, such as cabbage, highly seasoned, fried foods, usually omitted from regular diet.
2. Describe the following therapeutic diet and explain its rationale:
The Clear liquid diet
Limited to water, tea, coffee, clear broth, ginger ale, other carbonated beverages, strained and clear juices, Popsicles and plain gelatin.
Provides client with fluid and carbohydrate (in the form of sugar).
Does not supply adequate protein, fat, vitamins, minerals or calories.
A short term diet (24-36 hours) for clients after certain surgeries or in acute stages of infection, e.g., gastrointestinal tract.
Major objectives are: relieve thirst, prevent dehydration, and minimize stimulation of gastrointestinal tract.
2. Describe the following therapeutic diet and explain its rationale:
The full liquid diet
Contains only liquids or foods that turn to liquid at body temperature.
Includes all foods acceptable in clear liquid diet.
Also includes milk, puddings, custards, ice cream and sherbet, vegetable juices, refined or strained cereals, cream, butter, margarine, eggs (in custard or pudding), smooth peanut butter, and yogurt.
Eaten by clients who have GI disturbances or are otherwise unable to tolerate solid or semi-soft foods. NOT recommended for long-term use: low in iron, protein, and calories and cholesterol count is high because of the amounts of milk offered.
For long term use clients given nutritionally balanced oral supplement, such as Ensure or Sustacal.
2. Describe the following therapeutic diet and explain its rationale:
The soft diet
Easily chewed and digested.
For clients who have difficulty chewing and swallowing.
A low-residue (low-fiber) diet containing very few uncooked foods. Examples of foods allowed on a soft diet include: all foods on the clear/full liquid diets; lean, tender meat, fish or poultry which has been chopped or shredded; scrambled eggs; mashed potato; cooked vegetables chopped and shredded; cooked or caned fruits; rice, barley and pasta; soft cakes and bread puddings.
2. Describe the following therapeutic diet and explain its rationale:
Diet as tolerated
Ordered when client’s appetite, ability to eat, tolerance for certain foods may change.
E.g. on first postoperative day, client may be given a clear liquid diet. If no nausea occurs, normal intestinal motility returns, and the client feels like eating, the diet may be advanced to a full liquid, light, or regular diet.
3. Identify the learning needs of client regarding therapeutic diets. (K. p. 1202)
Some clients must follow certain diets (i.e. diabetics) for a lifetime. If diet is long term, client must understand it and develop a healthy, positive attitude toward it.
Assisting client/ support persons with special diets is a function shared by dietician or nutritionist and nurse. Dietician informs client/ support persons about specific foods allowed/ not allowed; assists the client with meal planning.
Nurse reinforces instruction, assists client to make changes, evaluates client’s responses.
4. Identify considerations to be taken when teaching a client about a therapeutic diet. (K. p. 1202)
All dietary instruction must be individually designed to meet the client’s intellectual ability, motivation level, lifestyle, culture, and economic status.
Both nutritionists and dietician can often help to adapt a diet to suit the client.
Simple verbal instructions need to be given and reinforced with written material. Family and support people must be included in the dietary instruction.
5. Identify interventions for stimulating a client’s appetite. (K. p. 1202)
• Provide familiar foods that the person likes. Often family members are happy to bring in foods from home, but may need guidance regarding dietary requirements.
• Select small portions so as not to discourage the anorexic client.
• Avoid unpleasant or uncomfortable treatments immediately before or after meals.
• Provide a clean, tidy environment that is free of unpleasant sights and odors (i.e., bedpans, irrigation sets, or even used dishes)
• Encourage or provide oral hygiene before mealtimes. This improves the client’s ability to taste.
• Relieve illness symptoms that distress appetite before mealtimes (i.e., analgesic for pain, antipyretic for fever, or allow rest for fatigue).
• Reduce psychologic stress. A lack of understanding of therapy, the anticipation of an operation, and the fear of the unknown can cause anorexia. Often the nurse can help by discussing feelings with the client, giving information and assistance, and allaying fears.
6. Common conditions in which enteral nutrition is indicated.
Mechanical Difficulties:
(Lutz, p. 281)
Make chewing and or swallowing impossible or difficult, include:
o Obstruction of the esophagus
o Weakness or nausea
o Mouth sores
o Throat inflammation
6. Common conditions in which enteral nutrition is indicated.
Intestinal Disease :
(Lutz, p. 281)
Client cannot digest or absorb food adequately:
o Malabsorption syndromes
6. Common conditions in which enteral nutrition is indicated.
• Client refuses to eat or cannot eat
(Lutz, p. 281)
o Anorexia nervosa
o Senile dementia
6. Common conditions in which enteral nutrition is indicated.
• Client is unable to consume a sufficient amount of food because of clinical condition
(Lutz, p. 281)
o Coma
o Serious infection
o Trauma victims
o Clients with large kilocalorie requirements
7. What are the six methods of enteral feeding that we discuss? In general why is enteral feeding used?
nasogastric, nasoenteric, gastrostomy, jejunostomy, PEG and PEJ. (K. p. 1204)
Enteral nutrition is provided when the client is unable to ingest foods or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted.
7. Discuss the following enteral feeding method:

nasogastric tube
Inserted through one nostril, down nasopharynx, and into alimentary tract.
This approach is often used for infants who are obligatory mouth breathers and premature infants who have no gag reflex.
Traditional; firm, large-bore nasogastric tubes are placed in the stomach. These are used for clients who have intact gag and cough reflexes, who have adequate gastric emptying, and who require short-term feedings.
Nasogastric tubes may be inserted for reasons other than providing nutrition. These include:
• 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 a laboratory analysis.
• To lavage (wash) the stomach in cases of poisoning or overdose of medications.
7. Discuss the following enteral feeding method:

nasoenteric tube
longer than a nasogastric tube; is inserted through one nostril down into the upper small intestine.
Used for clients who are at risk for aspiration, i.e., manifest the following:
• Decreased level of consciousness
• Poor cough or gag reflexes
• Endotracheal intubation
• Recent extubation
• Inability to cooperate with the procedure
• Restlessness or agitation
7. Discuss the following enteral feeding method:

Gastrostomy and jejunostomy devices
Used for long-term nutritional support, generally more that 6 – 8 weeks.
Conventional tubes are placed surgically or by laparoscopy through the abdominal wall into the stomach (gastrosomy) or into the jejunum (jejunostomy).
The surgical opening is sutured tightly around the tube or catheter to prevent leakage. Care of this opening before it heals requires surgical asepsis. When the incision heals, in about 10 to 14 days, the tube or catheter can be removed and reinserted for each feeding. Between feedings, a prosthesis may be used to close the ostomy opening.
7. Discuss the following enteral feeding method:

percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ)
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. The catheter has internal and external bumpers and an inflatable retention balloon to maintain placement. Once the opening has healed, replacement tubes can be inserted without the use of endoscopy.
8. Discuss 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, the 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, however, for verifying tube placement before each intermittent feeding and at regular intervals (at least once per shift) when continuous feedings are being administered.
8. Identify three methods used by the nurse to check tube placement. (K. p. 1209)
1. Aspirate 20 to 30 mL of gastrointestinal secretions.
2. Measure pH of the aspirated fluid.
3. Auscultate the epigastrium while injecting 5 to 20 mL of air.
8. Describe Method 1."Aspirate 20 to 30 mL of gastrointestinal secretions" for checking tube placement. (K. p. 1209)
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.
8. Describe Method 2."Measure pH of the aspirated fluid" for checking tube placement. (K. p. 1209)
This is the recommended method to determine tube placement. Testing the pH of aspirates can help distinguish gastric from respiratory and intestinal placement.
• Gastric aspirates tend to be acidic with a pH of 1 to 4, but as high as 6 if the client is receiving meds that control stomach 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 6.
Therefore, when pH readings are 6 or higher, radiographic confirmation of the tube placement needs to be considered, especially in clients with diminished cough and gag reflexes.
8. Describe Method 3."Auscultate the epigastrium while injecting 5 to 20 mL of air " for checking tube placement. (K. p. 1209)
Auscultate the epigastrium while injecting 5 to 20 mL of air. Air injected into the stomach produces whooshing, gurgling, or bubbling sounds over the epigastrium and the upper left quadrant. This method is less reliable than pH testing in predicting tube placement.
Currently, the most effective method appears top be radiographic verification of tube placement. Repeated x-ray studies are not feasible, however, in terms of cost and radiation risk. 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) Suspect tube dislodgement after episodes of coughing, sneezing, and vomiting.
9. What is a Bolus feeding?
Kozier, p.1210
Use syringe to deliver formula into stomach. Because formula is delivered rapidly it is not usually recommended; but may be used in long-term situations if client tolerates them. Feedings must be given only into stomach; client must be monitored closely for distention and aspiration.
9. What is a Intermittent feeding?
Kozier, p.1210
The administration of 300 to 500 mL of enteral formula several times a day. The stomach is preferred site; usually administered over at least 30 minutes.
9. What is a Continuous feeding?
Kozier, p.1210
Generally administered over 24 hour period using infusion pump that guarantees a constant flow rate. Essential when feedings are administered in small bowel. Used when smaller bore gastric tubes are in place or when gravity flow is insufficient to instill feeding.
9. What is a Cyclic feeding?
Kozier, p.1210
Feedings that are administered in less than 24 hours (12 to 16 hours). Often referred to as nocturnal feedings; allow client to attempt to eat normal meals through the day. Because nocturnal feedings may use higher nutrient densities and higher infusion rates than standard continuous feeding, particular attention needs to be given to monitoring fluid status and circulating volume overload.
10. Differentiate between open and closed enteral feeding systems.
(K. p. 1211)
Open systems use open-top container or syringe for administration. Enteral feeding for use with open systems are provided in flip-top cans or powdered formulas that are reconstituted with sterile water.
Closed systems consist of a pre-filled container that is spiked with enteral tubing and attached to the enteral access device. Pre-filled containers generally have 1 liter of formula and can hang safely for 24 to 36 hours if sterile technique is used.
11. Identify essential assessments to conduct before administering an enteral feeding. (K. p. 1216) AABCDD
• Abdominal distention, at least daily. Measure abdominal girth at the umbilicus: Abdominal distention may indicate intolerance to a previous feeding.
• Allergies to any food in the feeding:
Common allergenic foods include milk, sugar, water, water, eggs and vegetable oil
• Bowel sounds before each feeding or, for continuous feedings, every 4 to 8 hours:
i. To determine intestinal activity.
• Correct placement of tube, before feeding:
i. To prevent aspiration of feedings.
• Dumping syndrome: nausea, vomiting, diarrhea, cramps, pallor, sweating, heart palpitations, increased pulse rate, and fainting after a feeding:
i. Jejunostomy clients may experience these symptoms, which result when hypertonic foods and liquids suddenly distend the jejunum. To make the intestinal contents isotonic, body fluids shift rapidly from the client’s vascular system
i. • Diarrhea, constipation, or flatulence:
i. Lack of bulk in liquid feedings may cause constipation. Presence of hypertonic or concentrated ingredients may cause diarrhea and flatulence.
11. Identify essential assessments to conduct before administering an enteral feeding. (K. p. 1216) PUSH
• Presence of regurgitation and feelings of fullness after feedings:
i. May indicate delayed gastric emptying, need to decrease quantity or rate of feedings, or high fat content of the formula.
• Urine for sugar and acetone:
i. Hyperglycemia may occur if sugar content is too high
ii. Both increase as a result of dehydration.
• Serum BUN and sodium levels:
i. Feeding formula may have high protein content. If a high protein intake is combines with an inadequate fluid intake, the kidneys may not be able to excrete nitrogenous wastes adequately
• Hematocrit and urine specific gravity
12. Discuss client teaching for home enteral therapy. (K. p. 1217)
• Preparation of the formula.
• Proper storage of the formula.
• Administration of the feeding.
• Management of the enteral or parenteral access device.
• Daily monitoring needs.
• Signs and symptoms of complications to report.
• Whom to contact regarding questions or problems.
13. Identify nursing diagnoses for clients with nutrition imbalances.
(Handbook of Nursing Diagnosis)
1. Nutrition Imbalance: Less than body requirements
2. Nutrition Imbalance: More than body requirements
3. Nutrition Imbalance: Potential for more than body requirements
13. Identify nursing diagnoses for clients with enteral feeding problems:
(Handbook of Nursing Diagnosis)
1. Risk for infection related to gastrosomy incision and enzymatic action of gastric juices on skin
2. Risk for aspiration related to positioning of tube and individual
3. Acute pain related to cramping, distention, nausea
4. Vomiting related to type of formula, administration rate, temperature or route
5. Diarrhea related to adverse response to formula, rate, or temperature
13. Identify nursing diagnoses for clients with total parenteral: problems:
(Handbook of Nursing Diagnosis)
1. Risk for infection related to catheter’s direct access to blood stream
2. Risk for impaired skin integrity related to constant skin surface irritation secondary to catheter and adhesive
3. Risk for impaired oral/mucous membrane related to inability to ingest food/fluid