NUTRITION
INTERVENTION
WESLEYAN UNIVERSITY
PHILIPPINES
COLLEGE OF NURSING
WESLEYAN UNIVERSITY
PHILIPPINES
COLLEGE OF NURSING
TOPICS:
I.
II.
III.
IV.
Nutrition Care Process
Nutrition Diagnosis and Plan of Care
Food and Nutrient Delivery
Food Administration
 Oral
 Enteral
 Parenteral
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WESLEYAN UNIVERSITY
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Nutrition Care Process
• a systematic method to provide high-quality nutrition care.
• It was published as part of the Nutrition Care Model.
• The use of the NCP does not mean that all clients get the
same care; the process provides a framework for the
Registered Nutritionist/Nurse to customize care, taking into
account the client's needs and values and using the best
evidence available to make decisions.
• It is not intended to standardize nutrition care for each
patient/client, but to establish a standardized process for
providing care.
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The Nutrition Care Process consists of
distinct, interrelated steps:
•STEP 1. Nutrition Assessment
•STEP 2. Nutrition Diagnosis
•STEP 3. Nutrition Intervention
•STEP 4. Nutrition Monitoring and Evaluation
STEP 1: NUTRITION ASSESSMENT
• The first step of the Nutrition Care Process. Its purpose is to obtain adequate
information to identify nutrition-related problems.
• A systematic process of obtaining, verifying, and interpreting data to make
decisions about the nature and cause of nutrition-related problems
• It requires making comparisons between the information obtained and reliable
standards (ideal goals).
• An on-going, dynamic process that involves not only initial data collection but also
continual reassessment and analysis of patient/client/group needs. An assessment
provides the foundation for the nutrition diagnosis at the next step of the
Nutrition Care Process.
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Data Sources/Tools for Assessment
• Referral information and/or interdisciplinary records
• Patient/client interview (across the lifespan)
• Community-based surveys and focus groups
• Statistical reports; administrative data
• Epidemiological studies
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Types of Data Collected
• Nutritional Adequacy (dietary history/detailed nutrient intake)
• Health Status (anthropometric and biochemical measurements,
physical & clinical conditions, physiological and disease status)
• Functional and Behavioral Status (social and cognitive function,
psychological and emotional factors, quality-of-life measures,
change readiness)
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Nutrition Assessment Components
1.Review dietary intake for factors that affect health conditions and nutrition risk
2.Evaluate health and disease condition for nutrition-related consequences
3.Evaluate psychosocial, functional, and behavioral factors related to food access,
selection, preparation, physical activity, and understanding of health condition
4.Evaluate patient/client/group’s knowledge, readiness to learn, and potential for
changing behaviors
5.Identify standards by which data will be compared
6.Identify possible problem areas for making nutrition diagnoses
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The following types of critical thinking skills are especially needed in the assessment step:
1. Observing for nonverbal and verbal cues that can guide and prompt effective interviewing
methods;
2. Determining appropriate data to collect;
3. Selecting assessment tools and procedures (matching the assessment method to the situation);
4. Applying assessment tools in valid and reliable ways;
5. Distinguishing relevant from irrelevant data; Distinguishing important from unimportant data;
6. Validating the data;
7. Organizing & categorizing the data in a meaningful framework that relates to nutrition
problems; and
8. Determining when a problem requires consultation with or referral to another provider.
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STEP 2: NUTRITION DIAGNOSIS
 the second step of the Nutrition Care Process, and is the identification and
labeling that describes an actual occurrence, risk of, or potential for developing
a nutritional problem that dietetics professionals are responsible for treating
independently.
 At the end of the assessment step, data are clustered, analyzed, and
synthesized. This will reveal a nutrition diagnostic category from which to
formulate a specific nutrition diagnostic statement.
 It should not be confused with a medical diagnosis, which can be defined as a
disease or pathology of specific organs or body systems that can be treated or
prevented
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 A nutrition diagnosis changes as the patient/client/group’s response changes.
 A medical diagnosis does not change as long as the disease or condition exists.
 A patient/client/group may have the medical diagnosis of “Type 2 diabetes
mellitus”; however, after performing a nutrition assessment, dietetics
professionals may diagnose, for example, “undesirable overweight status”
or “excessive carbohydrate intake.”
 Analyzing assessment data and naming the nutrition diagnosis to provide a link
to setting realistic and measurable expected outcomes, selecting appropriate
interventions, and tracking progress in attaining those expected outcomes.
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3 distinct parts of Nutrition Diagnosis Components
1. Problem (Diagnostic Label)
2. Etiology (Cause/Contributing Risk Factors)
3. Signs/Symptoms (Defining Characteristics)
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1. Problem (Diagnostic Label)
• The nutrition diagnostic statement describes alterations in
the patient/client/group’s nutritional status. A diagnostic
label (qualifier) is an adjective that describes/qualifies the
human response such as:
 Altered, impaired, ineffective, increased/decreased, risk of, acute,
or chronic.
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2. Etiology (Cause/Contributing Risk Factors)
• The related factors (etiologies) are those factors
contributing to the existence of, or maintenance of pathophysiological,
psychosocial, situational,
developmental, cultural, and/or environmental problems.
 Linked to the problem diagnostic label by words “related to” (RT)
 It is important not only to state the problem but to also identify the cause of
the problem.
 This helps determine whether or not the nutritional intervention will
improve the condition or correct the problem.
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• It will also identify who is responsible for addressing the problem. Nutrition problems
are either caused directly by inadequate intake (primary) or as a result of other
medical, genetic, or environmental factors (secondary).
• It is also possible that a nutrition problem can be the cause of another problem. For
example, excessive caloric intake may result in unintended weight gain. Understanding
the cascade of events helps to determine how to prioritize the interventions.
• It is desirable to target interventions at correcting the cause of the problem whenever
possible; however, in some cases treating the signs and symptoms (consequences) of
the problem may also be justified.
• The ranking of nutrition diagnoses permits dietetics professionals to arrange the
problems in order of their importance and urgency for the patient/client/group.
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3. Signs/Symptoms (Defining Characteristics)
The defining characteristics are a cluster of subjective and
objective signs and symptoms established for each nutrition
diagnostic category. The defining characteristics, gathered during the assessment phase,
provide evidence that a nutrition-related problem exists and that the problem identified
belongs in the selected diagnostic category. They also quantify the problem and describe
its severity:
⊹ Linked to etiology by words “as evidenced by” (AEB);
⊹ The symptoms (subjective data) are changes that the patient/client/group feels and
expresses verbally to dietetics professionals; and
⊹ The signs (objective data) are observable changes in the patient/client/group’s
health status.
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Nutrition Diagnostic Statement (PES)
• Whenever possible, a nutrition diagnostic statement is written in
a PES format that states the Problem (P), the Etiology (E), and the
Signs & Symptoms (S). However, if the problem is either a risk
(potential) or wellness problem, the nutrition diagnostic
statement may have only two elements, Problem (P), and the
Etiology (E), since Signs & Symptoms (S) will not yet be exhibited
in the patient.
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Examples of Nutrition Diagnosis Statements (PES or PE)
• Excessive caloric intake (problem) “related to” frequent consumption of large
portions of high-fat meals (etiology) “as evidenced by” average daily intake of
calories exceeding recommended amount by 500 kcal and 12-pound weight gain
during the past 18 months (signs)
• Inappropriate infant feeding practice RT lack of knowledge AEB infant receiving
bedtime juice in a bottle
• Unintended weight loss RT inadequate provision of energy by enteral products
AEB 6-pound weight loss over the past month
• Risk of weight gain RT a recent decrease in daily physical activity following a
sports injury
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Critical Thinking
The following types of critical thinking skills are especially needed in the diagnosis
step:
⊹ Finding patterns and relationships among the data and possible causes;
⊹ Making inferences (“if this continues to occur, then this is likely to happen”);
⊹ Stating the problem clearly and singularly;
⊹ Suspending judgment (be objective and factual);
⊹ Making interdisciplinary connections;
⊹ Ruling in/ruling out specific diagnoses; and
⊹ Prioritizing the relative importance of problems for patient/client/group safety.
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Documentation of Diagnosis
Documentation is an on-going process that supports all of the steps in
the Nutrition Care Process. Quality documentation of the diagnosis step
should be relevant, accurate, and timely. A nutrition diagnosis is the
impression of dietetics professionals at a given point in time. Therefore, as
more assessment data become available, the documentation of the
diagnosis may need to be revised and updated. Inclusion of the following
information would further describe quality documentation of this step:
 date and time; and
 the written statement of nutrition diagnosis.
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Determination for Continuation of Care
• Since the diagnosis step primarily involves naming and describing
the problem, the determination for the continuation of care
seldom occurs at this step.
• Determination of the continuation of care is more appropriately
made at an earlier or later point in the Nutrition Care Process.
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STEP 3. NUTRITION INTERVENTION
• The third step of the Nutrition Care Process.
• An intervention is a specific set of activities and associated materials used to
address the problem.
• Nutrition interventions are purposefully planned actions designed with the
intent of changing a nutrition-related behavior, risk factor, environmental
condition, or aspect of health status for an individual, target group, or the
community at large.
• This step involves a) selecting, b) planning, and c) implementing appropriate
actions to meet patient/client/groups’ nutrition needs.
• The selection of nutrition interventions is driven by the nutrition diagnosis and
provides the basis upon which outcomes are measured and evaluated.
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Nutrition Intervention Components
This step includes two distinct interrelated processes:
1. Plan the nutrition intervention (formulate & determine a plan of
action)
 Prioritize the nutrition diagnoses based on the severity of the
problem; safety; patient/client/group’s need; likelihood that
nutrition intervention will impact problem and
patient/client/groups’ perception of importance.
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• Determine patient-focused expected outcomes for each nutrition diagnosis. The
expected outcomes are the desired change(s) to be achieved over time as a result
of nutrition intervention. They are based on nutrition diagnosis; for example,
increasing or decreasing laboratory values, decreasing blood pressure, or
decreasing weight.
• Expected outcomes should be written in observable and measurable terms
that are clear and concise.
• They should be patient/client/group-centered and need to be tailored to what
is reasonable to the patient’s circumstances and appropriate expectations for
treatments and outcomes.
• Confer with patient/client/group, other caregivers or policies, and program
standards throughout the planning step.
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2. Implement the nutrition intervention (care is delivered and actions are carried
out)
• Implementation is the action phase of the nutrition care process. During implementation,
dietetics professionals:
• Communicate the plan of nutrition care;
• Carry out the plan of nutrition care; and
• Continue data collection and modify the plan of care as needed.
• Other characteristics that define quality implementation include:
• Individualize the interventions to the setting and client;
• Collaborate with other colleagues and health care professionals;
• Follow up and verify that implementation is occurring and needs are being met; and
• Revise strategies as changes in condition/response occur.
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Critical Thinking
Critical thinking is required to determine which intervention strategies are implemented
based on the analysis of the assessment data and nutrition diagnosis. The following types of
critical thinking skills are especially needed in the intervention step:
• Setting goals and prioritizing;
• Transferring knowledge from one situation to another;
• Defining the nutrition prescription or basic plan;
• Making interdisciplinary connections;
• Initiating behavioral and other interventions;
• Matching intervention strategies with client needs, diagnoses, and values;
• Choosing from among alternatives to determine a course of action; and
• Specifying the time and frequency of care.
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Documentation of Nutrition Interventions
Documentation is an on-going process that supports all of the steps in the
Nutrition Care Process. Quality documentation of nutrition interventions should be relevant,
accurate, and timely. It should also support further intervention or discharge from care.
Changes in patient/client/group’s level of understanding and food-related behaviors must be
documented along with changes in clinical or functional outcomes to assure appropriate
care/case management in the future. Inclusion of the following information would further
describe quality documentation of this step:
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Documentation of Nutrition Interventions
•
•
•
•
•
•
Date and time;
•
Specific treatment goals and expected
outcomes;
Recommended interventions,
•
individualized for the patient;
Any adjustments of plan and
•
justifications;
Patient receptivity;
Referrals made and resources used;
Any other information relevant to
providing care and monitoring
progress over time;
Plans for follow-up and frequency of
care; and
The rationale for discharge if
appropriate.
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STEP 4. Nutrition Monitoring and Evaluation
• The fourth step of the Nutrition Care Process.
• Monitoring specifically refers to the review and measurement of the
patient/client/group’s status at a scheduled (preplanned) follow-up
point about the nutrition diagnosis, intervention plans/goals, and
outcomes, whereas Evaluation is the systematic comparison of current
findings with the previous status, intervention goals, or a reference
standard.
• Monitoring and evaluation use selected outcome indicators (markers)
that are relevant to the patient/client/group’s defined needs, nutrition
diagnosis, nutrition goals, and disease state.
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• Innovative methods can be used to contact patients/clients to
monitor progress and outcomes.
• Patient confidential self-report via mailings and telephone
follow-up are some possibilities.
• Patients being followed in disease management programs can
also be monitored for changes in nutritional status.
• Alterations in outcome indicators such as hemoglobin A1C or
weight are examples that trigger reactivation of the nutrition
care process.
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Types of Outcomes Collected
The outcome(s) to be measured should be directly related to the nutrition
diagnosis and the goals established in the intervention plan. Examples include, but
are not limited to:
1. Direct nutrition outcomes (knowledge gained, behavior change, food or
nutrient intake changes, improved nutritional status);
2. Clinical and health status outcomes (laboratory values, weight, blood pressure,
risk factor profile changes, signs and symptoms, clinical status, infections,
complications);
3. Patient/client-centered outcomes (quality of life, satisfaction, self-efficacy, selfmanagement, functional ability); and
4. Health care utilization and cost outcomes (medication changes, special
procedures, planned/unplanned clinic visits, preventable hospitalizations,
length of hospitalization, prevent or delay nursing home admission).
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Nutrition Monitoring and Evaluation Components
This step includes three distinct and interrelated processes:
1. Monitor progress
In monitoring the patient’s progress, the following guidelines may be used:
• Check patient/client/group understanding and compliance with a plan;
• Determine if the intervention is being implemented as prescribed;
• Provide evidence that the plan/intervention strategy is or is not changing
patient/client/group behavior or status;
• Identify other positive or negative outcomes;
• Gather information indicating reasons for lack of progress; and
• Support conclusions with evidence.
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2. Measure outcomes
• Select outcome indicators that are relevant to the nutrition
diagnosis or signs or symptoms, nutrition goals, medical diagnosis,
and outcomes and quality management goals.
• Use standardized indicators to:
a. Increase the validity and reliability of measurements of change;
and
b. Facilitate electronic charting, coding, and outcomes
measurement.
3. Evaluate outcomes
• Compare current findings with previous status, intervention goals,
and/or reference standards.
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Documentation of Monitoring and Evaluation
Standardized documentation enables the pooling of data for
outcomes measurement and quality improvement purposes. Quality
documentation should include:
• Date and time;
• Specific indicators measured and results;
• Progress toward goals (incremental small change can be
significant therefore use of a Likert type scale may be more
descriptive than a “met” or “not met” goal evaluation tool);
• Factors facilitating or hampering progress;
• Other positive or negative outcomes; and
• Plans for nutrition care, monitoring, and follow up or discharge.
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ii. Nutrition Diagnosis and Plan of Care
NUTRITION PROBLEMS AND NEEDS
⊹ A variety of medical problems can affect your appetite. Your illness,
medicines, or surgery can cause these problems. Many patients
become frustrated when they know they need to eat to get well
but they aren't hungry, or when they gain weight because they are
fatigued and unable to exercise. The following are nutritional
problems and some suggestions for some possible solutions
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1. Decreased Appetite
Lack of appetite, or decreased hunger, is one of the most
troublesome nutrition problems you can experience. Although it is a
common problem, its cause is unknown. Some medicines might stimulate
your appetite. Ask your doctor if such medicines would help you.
Solutions:
a. Eat smaller meals and snacks more frequently. Eating six or seven or
eight times a day might be more easily tolerated than eating the same
amount of food in three meals.
b. Talk to your doctor. Sometimes, poor appetite is due to depression,
which can be treated. Your appetite is likely to improve after
depression is treated.
c. Avoid non-nutritious beverages such as black coffee and tea.
d. Try to eat more protein and fat, and less simple sugars.
e. Walk or participate in a light activity to stimulate your appetite.
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2. Heartburn
Heartburn can occur for many reasons, including overeating, eating
certain foods, taking medicines, or as a result of surgery.
Solutions:
a. Avoid foods that have caused heartburn before. Some foods commonly
associated with heartburn are highly seasoned, greasy or fried foods,
chocolate, alcohol, and beverages that contain caffeine (coffee, tea, and
soft drinks).
b. Eat five or six smaller meals a day instead of three large meals.
Decreasing the amount of food in your stomach eases digestion and
reduces the chances of heartburn.
c. Remain standing or sitting for at least two hours after eating.
If lying down, keep upper body raised at a 45-degree angle.
d. Eat your last meal several hours before going to bed.
e. Take antacid one hour after meals to relieve heartburn. You can also try
taking antacids before going to bed. If you take antacids frequently, tell
your doctor or dietitian.
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3. Diarrhea
Diarrhea is an increase in either the number of stools, the amount of liquid in the stools, or
both. Medicines, a reaction to certain foods, stress, and ordinary colds or flu can cause diarrhea.
Solutions:
a. Drink eight or more cups of liquids per day.
b. Add one to two cups of liquids to the daily eight cups for every episode of the loose, watery
stool to replace losses.
c. Talk with your doctor or dietitian about increasing or decreasing the amount of fiber you
eat.
d. Drink a variety of beverages to help replace lost liquids and nutrients. Try water, coffee,
tea, iced tea, lemonade or fruit-flavored drinks, fruit or vegetable juice, broth, milk, or
cream soup.
e. Eat soft foods that contain large amounts of liquid, such as sherbet, gelatin, yogurt, and
pudding.
f. Use less sugar and fat. Limiting sugar and fat might decrease the amount of water in the
intestine and reduce the number of episodes of diarrhea.
g. Ask your doctor whether adjusting your medicines might help relieve diarrhea. Do not
change your medicines without first talking to your doctor.
h. Don't take over-the-counter (non-prescription) drugs for diarrhea without talking to your
doctor.
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4. Constipation
Constipation occurs when bowel movements become difficult or
infrequent, usually more than 48 hours apart. Constipation can be caused
by medicines and by not drinking or eating enough liquids or food, and
inactivity.
Solutions:
a. Drink eight or more cups of fluids per day, such as water, coffee,
tea, juice, or flavored beverages.
b. Drink something hot as the first beverage in the morning, such as
hot water, coffee, tea, or hot apple cider. Hot liquids might
stimulate a bowel movement.
c. Drink 1/2 to 1 cup of prune juice in the morning to stimulate a
bowel movement.
d. Increase the fiber in your foods. Try whole-grain bread, fresh
fruits, whole grain cereals, and fresh vegetables.
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e. Emphasize fruits that stimulate the bowels, such as watermelon,
plums, and other summer fruits, and avoid fruits that constipate,
such as bananas.
f. Add two to four tablespoons of unprocessed wheat bran to foods
and drink plenty of liquids. (Liquids help bran to be effective.) Try
bran sprinkled over hot or cold cereal, casseroles, or mixed with
applesauce, pancake batter, pudding, muffin batter, milkshakes, or
cookie dough.
g. Activity such as walking helps normalize bowel function.
h. Plan trips to the bathroom immediately after meals since eating is a
natural stimulus for having a bowel movement.
i. If constipation continues, call your doctor. Your doctor might
prescribe a stool softener or laxative. Don't take any medicines,
including over-the-counter (non-prescription) medicines, to treat
constipation without talking to your doctor.
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NUTRITION
INTERVENTION
FOOD ADMINISTRATION
• Good and nutritious food is a major contributor to quality of life and
wellbeing.
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Oral Nutrition
• Oral Nutritional Supplements (ONS) are sterile liquids, semi-solids, or
powders, which provide macro and micronutrients.
• They are widely used within the acute and community health settings
for individuals who are unable to meet their nutritional requirements
through an oral diet alone.
• ONS use must be approved by the Advisory Committee on Borderline
Substances (ACBS).
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Indications for use include:
1.
2.
3.
4.
5.
6.
7.
8.
Short bowel syndrome
Dysphagia
Intractable malabsorption
Pre-operative preparation of undernourished patients
Inflammatory bowel disease
Total gastrectomy
Bowel fistulae
Disease-related malnutrition (chronic/acute)
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Oral Nutrition
• ONS may be prescribed in the short term during acute illness, but
also for individuals with long term chronic conditions.
• The role of ONS is to complement nutritional intake, and
simultaneous information around improving oral intake should be
provided.
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• Some ONS are available to buy over the counter in supermarkets or pharmacies
(usually in powder form which is mixed with milk or water) but the majority of
ONS is only available on prescription ideally following advice from a registered
dietitian.
• ONS often contain macronutrients (protein and/or energy) and micronutrients
(vitamins and minerals) at varying levels of concentrations. Therefore, not all
ONS are nutritionally complete, meaning that they cannot be used as a sole
source of nutrition.
• Individual dietetic assessment will take into account nutritional requirements
and taste and texture preferences to ensure a tailored prescription is advised.
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Table 4.5 Most Common Types of Oral Nutritional
Supplements (ONS) Available
Type
Juice type
Milkshake type
Notes
Volume ranges from 200-220ml with an energy density of 1.25-1.5kcal/ml. They are fat-free
Volume ranges from 125-220ml, energy density ranges from 1-2.4kcal/ml. Also available with
added fiber.
High-energy
Volume ranges from ~125-350ml, ideally made up of full cream milk to give an energy
powders
density of 1.5-2.5kcal/ml.
Soup type
Semisolid/dysphagia
ranges
High protein
Low volume high
concentration
(shots)
Volume ranges from 200-330ml. Some are ready-mixed and others are powder and can be
made up with water or milk to give an energy density of 1–1.5kcal/ml.
Range of presentations from thickened liquids (stage 1 and 2) to smooth pudding styles
(stage 3), with an energy density of ~1.4-2.5kcal/ml.
Range of presentations; jellies, shots, milkshake style containing 11-20g of protein in
volumes ranging from 30–220ml.
These are fat and protein-based products that are taken in small quantities (shots), typically
30-40ml as a dose taken 3-4 times daily.
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What else should be considered?
• Further information regarding the suitability of ONS should be checked with individual
manufacturers, for example, gluten or lactose-free, halal or kosher.
• ONS should be used with caution in those with dysphagia to ensure the correct consistency
is provided. Thickeners can be added to obtain the recommended consistency.
• A range of flavors should be offered to avoid taste fatigue. There is an emerging group of
ONS which are designed for individuals over the age of 65 years who can be at risk of
vitamin D deficiency.
• Other products may be useful in patients with specific medical conditions where fluid and
electrolyte balance is important. Patients with short gut may not tolerate hyperosmolar
ONS as they may increase stoma losses.
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Monitoring
ONS should not be prescribed without being monitored to ensure that they
remain appropriate and are being taken as prescribed. ONS may be stopped when:
1.
Dietary intake is meeting nutritional requirements.
2. Weight has increased to target.
3. BMI is within a healthy range.
4. The individual’s medical condition has changed, e.g. an individual with a
swallowing difficulty recovers some/all of their functionality.
5. The individual can no longer tolerate them due to taste fatigue.
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Enteral Nutrition
• All people need food to live. Sometimes a person cannot eat any or
enough food because of an illness. Others may have a decreased
appetite, difficulties in swallowing, or some type of surgery that
interferes with eating. When this occurs, and one is unable to eat,
nutrition must be supplied differently. One method is “enteral nutrition”
or “tube feeding.”
• Tube feeding is a special liquid food mixture containing protein,
carbohydrates (sugar), fats, vitamins, and minerals, given through a tube
into the stomach or small intestine.
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Table 4.6 is based from Home
Tube Type
Nasogastric
Fine bore
feeding
tubes ≤12fr
Time
Frame
Shorttermgenerally
less than
3 days
Nasojejunal Shortterm generally
less than
90 days
Common
Indications
 Early poststroke
 Inadequate
oral intake
 Acute
swallowing
problem
Common
Insertion
Methods
Bedside
Hazards
Ensuring
tip in
stomach
 Reduced
 Bedside
Insertion
gastric
magnetic
more
emptying
imager
complex
 Pathology in  Endoscopy
esophagus
 Radiological
or stomach
screening
Key Interventions
the pH of aspirate on
insertion then before
every tube use/ daily if
fed over 24 hours to
check tip position.
Also check if:
1. Any new or
unexplained
respiratory symptoms
or if oxygen
saturations decrease.
2. Episodes of vomiting,
gagging, or coughing
spasms.
X-ray after insertion to
check tip position then
if tube moves or
symptoms.
Common Issues
Repeated displacement
 Retention devices may be
useful
Blockage
 50ml enteral syringe + warm
water
 care with medications
Blockage
 may be kinked if too much
tube inserted - pull back to 80100cm at the nose
 avoid drugs if at all possible
 50ml enteral syringe + warm
water
Displacement
 Retention devices may be
50
useful
Table 4.6 Different Types of Tubes
Tube
Type
Time
Frame
Long-term –
G
A
S
T
R
O
S
T
O
M
Y
Common
Indications
 Longer-term
Common
Insertion
Methods
Hazards
Endoscopy
1. Inadequate
Radiology –
generally
in
more than 30
neurological
push or pull
days
disease
technique
 Esophageal
pathology
 Head and
neck cancer
 Brain injury
Surgery
assessment
before insertion
2. Complications of
insertion
 Peritonitis
 inadvertent
Key
Interventions
Common Issues
Displacement
Advance/
Rotation 12weekly
pH checks if
tube replaced
appropriate
If less than 4 weeks post-insertion, great care
needed for replacement
If more than 4 weeks post-insertion, re-
insertion of a spare tube or balloon
gastrostomy tube as soon as possible to
avoid closure of tract. Closure of the tract
puncture of the
72-hour post-
colon
procedure
Local leakage
care
 Skin protection
 bleeding
can occur within 4 hours.
 infection
 Consider whether bumper too tight
 risk of aspiration
Abscess
1. Displacement
 Antibiotics
 May need the removal of gastrostomy
Damage to tube
Connections often replaceable
51
Tube
Type
Time
Frame
Long-
J
E
J
U
N
O
S
T
O
M
Y
Common
Indications
Common
Insertion
Methods
Gastroparesis Endoscopy
term -
As NJ but
generally
longer-term
(direct)
Endoscopy
Hazards
1.More difficult
Key
Interventions
Common Issues
Displacement
to insert than
 If less than 4 weeks’ post-insertion,
gastrostomy
great care needed for replacement
 If more than 4 weeks post-insertion,
over 30
(extension via
2.Complication
days
gastrostomy)
of insertion:
re-insertion spare tube or catheter as
-Peritonitis
soon as possible to avoid closure of
-inadvertent
tract.
Radiology
(transgastric)
Surgery
puncture of
Blockage
the colon
 50ml enteral syringe + warm water
-bleeding
Local leakage
-infection
Skin protection
1.Extensions
Consider whether bumper too tight
liable to
Abscess
displacement
 Antibiotics
Small bowel
volvulus
 May need the removal of
jejunostomy
Damage to tube
Connections often replaceable
52
Parenteral Nutrition
• Parenteral nutrition (PN) is intravenous administration of nutrition,
which may include protein, carbohydrate, fat, minerals and electrolytes,
vitamins, and other trace elements for patients who cannot eat or absorb
enough food through tube feeding formula or by mouth to maintain good
nutrition status. Achieving the right nutritional intake on time can help
combat complications and be an important part of a patient’s recovery.
Parenteral nutrition is sometimes called Total Parenteral Nutrition (TPN)
WESLEYAN UNIVERSITY – PHILIPPINES
COLLEGE OF NURSING
53
WESLEYAN UNIVERSITY
PHILIPPINES
COLLEGE OF NURSING
Parenteral Nutrition
54
WESLEYAN UNIVERSITY
PHILIPPINES
COLLEGE OF NURSING
• People of all ages receive parenteral nutrition. It may be given
to infants and children, as well as to adults.
• People can live well on parenteral nutrition for as long as it is
needed. Many times, parenteral nutrition is used for a short
time; then it is lessened or discontinued when the person
begins to switch to tube feeding or eat enough by mouth.
Parenteral nutrition bypasses the normal digestion in the
gastrointestinal (GI) tract. It is a sterile liquid chemical formula
given directly into the bloodstream through an intravenous (IV)
catheter (needle in the vein).
55
WESLEYAN UNIVERSITY
PHILIPPINES
COLLEGE OF NURSING
Patients may need PN for any variety of diseases or
conditions that impair food intake, nutrient digestion, or
absorption. Some diseases and conditions where PN is
indicated include but are not limited to short bowel syndrome,
GI fistulas, bowel obstruction, critically ill patients, and severe
acute pancreatitis. Some patients may require this therapy for a
short time and other patients have received PN at home for a
lifetime
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WESLEYAN UNIVERSITY
PHILIPPINES
Responsibilities of Health Personnel
1. Discard all unused or cloudy fluids.
2. Do not add drugs and other mixtures to a solution containing protein.
3. Refrigerate solutions until they are used.
4. Be aware that dates should be on tube feedings, and that they should not be given the past 24 hours of date.
5. Be alert for signs of gas, regurgitation, cramping, and diarrhea, and be prepared to intervene.
6. Take necessary precautions when using nutrient solutions because they are excellent sources for bacterial growth.
7. Be especially alert for signs of hypo- or hyperglycemia when TPN is used and intervene if necessary.
8. Assist the patient in adjusting to an alternate feeding method. Many patients experience stress due to fear and
concern about unfamiliar feeding methods.
9. Encourage and practice good oral hygiene measures with the patient, even though he or she is not eating by
mouth.
COLLEGE OF NURSING
57
WESLEYAN UNIVERSITY
PHILIPPINES
COLLEGE OF NURSING