Summer 2009 Nutrition Bowel Elimination Whiteln

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Principles of Nutrition and Bowel Elimination

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Pam Bellefeuille

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RN MN APRN-BC CNS CEN All rights reserved pamb 709

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___________________________________ • Content Topics:

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• GI/Nutrition/Elimination assessments • Assessment and Care of NG tubes Feeding Tubes Central Lines • PPN/TPN • Bowel Diversions/ Ostomies

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Assessnutritional status What are patient risk factors? What are the priority assessments? What labs would contribute to the pt assessment? What options are available to nutritionally support this pt?

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Assessbowel elimination What are the patient risk factors? What are the priority assessments ? What labs would contribute to the pt assessment? What options are available to support bowel elimination pt?

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Mrs. H., a 46 year old female with a long history of ulcerative colitis (UC), admitted for SBO (small bowel obstruction); multiple hospitalizations for episodic UC issues over past year; c/o continuous abdominal cramping “4/10”; abdomen distended and tight; nauseous; vomiting clear yellow/green emesis; had 6 blood-tinged stools overnight; perineum excoriated; no stool for past 4 hrs; feels “weak and washed out”; has lost 15 lbs X 3 months from poor appetite; pt thin, gaunt, looks pretty miserable. BP ↔108/60 P 100 reg BP 98/56 P 120 reg R 22 T 99.8 O2 Sat 95%

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___________________________________ Assessment: Mrs. H’s LABS • • • • • • • •

Na146 (135-145) K3.5 (3.5-5.0) Hgb12 (14-18) HCT 38 (40-52) WBC10,000 (5,000-10,000) Albumin2.4 (3.5-5) Prealbumin10 (15-36) Bldgluc80 (70-110)

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___________________________________ Assessment: Nutrition • Recent weight loss? • Change in appetite or diet recently? • GI symptoms such as nausea, vomiting, diarrhea, constipation, anorexia? • Energy level changed? • Current medical issues? • Medications; prescription/OTC/other?

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Assessment: Nutrition • Assessfor :

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Hydration/intake/I&O Diet/NPO/Tube Feed/ TPN/PPN Abdominal distention/ascites Nutritional status/ de-conditioning/wasting, Mobility/Immobility

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Assessment : Bowel Elimination Basic Concept: “Everybody Poops” • Last Bowel Movement (BM) • Bowel Sounds; Passing Flatus/Stool • Bowel habits • Rectal bleeding • Meds

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___________________________________ MD Orders • • • • • • • •

NPO Insert NG; NG to low intermittent suction IV D5NS at 125/hr Hydrocortisone 100 mg IV daily Morphine Sulfate 2 mg IV for pain now PCA orders per Pain Team Consult CNS for central line access Consult Nutrition Team for PPN/TPN

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___________________________________ Nasogastric tube (NGT) • NGT (nasogastric tube) removes gastric secretions with intermittent or continuous suction OR • NGT without suction can be used for meds and/or short term enteral nutrition (<2wks)

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According to the Metheny article, which assessment technique is the most reliable for verifying NG tube placement?

• A. Auscultate over the gastric area while injecting 30ml of air into the NG tube • B. Observe the back of the throat for curling of the tube • C. Place the distal end of the NG tube in water and assess for bubbling • D. Aspirate gastric contents and test ph

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NGT

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___________________________________ Nasogastric tube(NGT) Priority to confirm placement : x-ray pH (<6) with color of contents measure to distal end • Maintain patency: 30 ml. NS flush; properly crush/ dissolve meds • Assess electrolytes; hydration/nutrition/elimination

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Central Lines • Peripherally Inserted Central Catheter (PICC)/ Subclavian Line(single, double or triple lumen) • Confirm placement • Assess/Maintain patency per standard flush • Use aseptic sterile technique • Assess for sepis; air “Central” Line embolism

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Triple lumen subclavian

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• PPN: short term, peripheral or central line, <10% dextrose solution

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NGT

TPN: long term;

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PPN/TPN : Peripheral and Total Parenteral Nutrition

central line only; complete nutrition; lipids needed once a week, >25%dextrose solution Monitor blood glucose Taper up and taper down

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PO TPN

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GT

PPN FT

Enteral Feeding Tubes (if the “gut” is working)

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JT

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___________________________________ MrsH calls the nurse, c/o acute onset of severe abdominal pain, increasing abdominal distention, N/V, no flatus or diarrhea, NG tube draining large amounts of brown drainage, guaiac negative for blood. IV pain med administered with little relief. BP 93/60 P 116 R 24 and slightly labored; O2 Sat 97% The surgeon assesses Mrs H and schedules her for an emergency bowel resection and ileostomy.

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Intestinal Diversions : Ostomies

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___________________________________ Intestinal Diversions : Ostomies • Ileostomy vs Colostomy • Monitor nutrition , electrolytes, hydration • Effluent drainage/ skin integrity • Self care issues • Body image issues (self and family) • Collaborate with ETRN (enterostomal RN)

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