Cpne

Front 1

Fluid Management

Bolus Enteral feeding – when assigned

Back 1

Bolus Enteral feeding -Assess(formula & ml’s, inspect system & skin), Imp (gastric residual,reinstill, ml’s, ensure feeding), Eval (response), Doc (formula & ml’s,integrity of system & skin, ml of formula, time, amount residual &reinstill, response)

Start: Wash & ID pt, selectprescribed formula, Position patient at 30 degrees or higher.

Assess: a. Patients educational needs related to BolusEnteral feeding.

b. Inspect integrity of the system.

c. Skin surrounding entry site

Implement: a. Provide education.

b. Measure gastricresidual w/a – from PCS form, CE or RN at what residual volume feeding is held.

c. Reinstall gastricresidual w/a.

d. regulate flow rate todeliver prescribed volume of feeding.

e. Ensure patientreceived prescribed volume of feeding.

f. Start feeding within+/- 30 minutes of scheduled tine.

Evaluate: a. Patients response to feeding.

Document: a. Feeding formula &flow rate

b. Integrity of system

c. appearance of skin

d. Volume of feedingduring PCS

e. Time of feeding,initial bottom of FM flow sheet

f. Amount of gastricresidual, amount reinstilled.

g. patient response.

Patientreceiving a 200 ml bolus of Peptaman Nutritional Supplement , The peg tube is patent and intact. The skin surrounding the insertion site ispink and not inflamed. The total volume of the feeding was 200 ml and wascompleted at 12:00. The gastric residualwas 50 ml, and 50 ml re instilled. The patient was satisfied with the feedingand no complaints of discomforted noted.

NANDA:

Imbalanced Nutrition: less than bodyrequirements: monitor state of oralcavity, provide oral hygiene, make food available form morning to evening.

Impaired swallowing: Provide meals ina quite environment, maintain oral hygiene.

Impaired oral mucous membranes: Useform sticks to moisten, oral membranes, Provide oral hygiene