Chapter 10
Diet and Nutrition
Diet is a basic human need. People require the essential nutrients for the normal physiologic
function of all body processes and growth and metabolism of all body tissues. Medical nutrition
therapy is now recogniized as a disease specific treatment modality. In some illnesses, nutrition
therapy may be the major treatment for disease control, such as Type I diabetes and mild
hypertension. Other conditions, such as inflammatory bowel disease may need nutrition support
such as enteral nutrition and parenteral nutrition. During the mid-1800s Florence Nightingale
stressed the nurse's role in the nutrition treatment. Since then, the nurse's role in nutrition and diet
therapy has changed. So nurses should master the knowledge of nutrition, assess the need of
nutrition properly and give the guidelines of nutrition to promote patients to recover as soon as
possible.
Section 1
Introduction
Body Requirement for Nutrients
As you body lives each day, it must use energy. The energy that fuels the body's work comes
indirectly from the sun by way of plants. Plants capture and store the sun's energy in their tissues
as they grow. When you eat plant-derived foods such as fruits, grains, or vegetables, you obtain
and use the solar energy that have stored. When you eat animal tissues, you are eating compounds
containing energy that came originally from the sun.
The body also requires six kinds of nutrients—families of molecules indispensable to its
functioning—and foods deliver these. Four of these six are organic; that is, the nutrients contain
the element carbon derived from living things. The human body and foods are made of the same
materials, arranged in different ways.
Among the four organic nutrients, three are energy-yielding nutrients, meaning that the body
can use the energy they contain. The carbohydrate and fats are especially important
energy-yielding nutrients. As for protein, it does double duty: it can yield energy, but it also
provides materials that from structures and working parts of body tissues.
The fifth and sixth classes of nutrients are the vitamins and the minerals. These provide no
energy to the body. A few minerals serve as parts of body structures (calcium and phosphorus, for
example, are major constituents of bone), but all vitamins and minerals act as regulators. As
regulators, the vitamins and minerals assist in all body processes: digesting food; moving muscles;
disposing of wastes; growing new tissues; healing wounds; obtaining energy from carbohydrate,
fats, and protein; and participating in every other process necessary to maintain life.
The Relationship Between Nutrition and Human Health
Rational diet and balanced nutrition are essential conditions to maintain human health. If the
foods you eat provide too little or too much of any nutrient today, your health may suffer just a
little. If the foods you eat provide too little or too much of one or more nutrients every day for
years, then, by the time you are old, you may well suffer severe disease effects.
The point is that a well-chosen array of foods supplies enough energy and enough of each
nutrient to prevent malnutrition. Malnutrition includes deficiencies of nutrients, imbalances, and
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excesses, any of which can take a toll on health over time.
Section 2
Hospital Diets
Hospital diets are categorized as basic diets, therapeutic diets and test diets.
Basic Diets
Basic diets are the foundation of the other diets. Basic diets, including general diet, soft diet,
semi-liquid diet and liquid diet.
General diet
Applicable clients Clients with normal digestive and absorptive function, with normal
temperature, and those during the process of recovery or without diet limit.
Reference Balanced nutrition, easily digested, not stimulating, 3 meals a day with total energy
of 2200-2600kcal/d, and protein of 70-90g/d.
Soft diet
Applicable clients Clients having difficulty in chewing, or gastrointestinal function disorders,
elders, infants and those during postoperative recovery.
Reference Balanced nutrition, easily chewed, not stimulating, soft food such as noodle, steamed
bread, vegetables, well-cooked mince meat, 3-4 meals a day with total energy of 2200-2400kcal/d
and protein of 60-80g/d.
Semi-liquid diet
Applicable clients Clients with fever, oral diseases or gastrointestinal disorders or having
difficulty in chewing and swallowing, or those during postoperative period.
Reference Not stimulating, easily chewed and swallowed, semi-liquid food such as rice
porridge, noodle, bean-curd and dumpling, small frequent meals with fixed quantity of each staple
food, 5 meals recommended a day with total energy of 1500-2000kcal/ d and protein of 50-70g/d.
Liquid diet
Applicable clients Clients with hyperthermia, oral diseases, acute inflammation, having
difficulty in swallowing acute gastrointestinal disturbances, or those in critical conditions, during
postoperative period.
Reference EasjIy swallowed and digested liquid food such as milk, bean milk, fruit juice, only
for temporary use because of insufficient energy, 6-7 meals a day 200-250ml each time with total
energy of 836-1195kcal/ d and protein of 40~50g/ d.
Therapeutic Diets
Therapeutic diets are based on the basic diets and used as treatment by adjusting total energy
and certain nutrients.
High energy diet
Applicable clients Clients with diseases of high consumption of energy; such as tuberculosis,
large area burns, liver diseases, and hyperthyroidism.
Reference In addition to basic diet, 2 more meals are added a day such as milk, bean milk, egg,
cake, chocolate, with total energy of 3000kcal/d.
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High protein diet
Applicable clients Clients with long-term consumptive diseases (such as tuberculosis),
malnutrition, anemia, burns, malignancy, nephritic syndrome, hypoprotein, and those before or
after operation, in pregnancy, and lactation.
Reference In addition to basic diet ,high-protein food such as meat, fish, egg, beans are added
with total amount of protein 1.5-2g/ (kg．d), < 120g/d and total energy of 2500-3000kcal/ d.
Low protein diet
Applicable clients Clients who need limited protein intake, such as acute nephritis, uremia, and
hepatic coma.
Reference Limited protein intake with total amount of protein < 40g/d for adult, subject to
variation of 20-30g/ d according to conditions.
Low salt diet
Applicable clients Clients with hypertension, congestive heart failure, ascites, aura eclampsia,
chronic nephritis, and hydropexis sodium and retention.
Reference Restricted salt in cooking and diet, with total amount of salt < 2g/ d for adult except
for natural sodium chloride in food. Pickled food, such as pickles, ham, and bacon is forbidden.
Salt free and low sodium diet
Applicable clients Same as those of low salt diet, in addition to severe edema clients.
Reference No salt in cooking except for natural sodium chloride in food, with no more than
0.5g/d, High-sodium food and medicine such as alkaline foods, soda, carbonated drinks is
forbidden.
Low fat diet
Applicable clients Clients with hepatic, cystic, and pancreatic diseases, hypercholesterolemia,
arteriosclerosis, coronary heart disease and obesity.
Reference Restricted oil and forbidden fat, cream, animal' s brain, yolk, and fried food.
Unlimited vegetable oil for clients with hypercholesterolemia and arteriosclerosis, with total fat
amount <50g/ d. Restricted animal fat intakes especially for clients with hepatic, cystic, and
pancreatic diseases, with fat amount < 40g/ d.
Low cholesterol diet
Applicable clients Clients with arteriosclerosis, hypertension, coronary heart disease, high
serum cholesterol levels.
Reference High-cholesterol food such as yolk, animal viscera, bacon, fat, animal oil, is
restricted with total cholesterol amount<300mg/ d.
Low residue or residue free diet
Applicable clients Clients with diarrhea, enteritis, typhoid, dysentery, rheumatic fever, and
those after gastrointestinal operation, Gastroesophageal varication, rectum and anus operation.
Reference High fiber food such as roughage, bamboo shoot, and leek is forbidden or restricted.
Hard food with smashed bones is forbidden. keep clients informed that high calorie food usually
contain low residue.
High food fiber diet
Applicable clients Clients with constipation, obesity, diabetes, and hyperlipidemia.
Reference High fiber food, such as leek, celery, cabbage, roughage and beans are recommended.
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Test Diets
Test diets, also known as diagnostic diets, are used to help diagnosis and insure accurate
testing by adjusting the contents of diets in special time.
Occult blood test diet
The three-day test diet is used for preparation of occult blood test to assist the diagnosis of
gastrointestinal bleeding. The client who is going to have the test is forbidden during this period
any food that can lead to a false positive result, such as meat, poultry, medicine and food rich in
iron, and green vegetables. The test sample will be taken on the forth day.
Cholecystography test diet
The test is used in diagnosing gallbladder disease, bile duct disease and hepatic bile duct
disease.
Before the test day, the client should have high fat diet for lunch and fat free, low protein,
high carbohydrates diet for supper, followed by contrast after which food and water are absolutely
forbidden until the morning of the test day.
The client should not have breakfast on the test day. After the first X-ray examination, the
client can have a high fat meal (fat 25-50g) if the gall bladder develops well. In 30 minutes the
client can have the second X-ray examination.
Creatinine test diet
The three-day test is used. to check the kidney filtration function. During this period, meat,
poultry, fish, tea, and coffee are absolutely forbidden, and protein intake is also limited to the total
amount of protein<40g/d. The test sample will be taken on the third day.
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thyroid uptake test diet
The two-week test is used to check the function of thyroid. During this period, food rich in
iodine, such as kelp, jellyfish, shrimp, iodized salt as well as iodine for skin disinfection are
absolutely forbidden.
Section 3
Nutrition Assessment
The purpose of a nutritional assessment is to identify clients at risk for malnutrition and those
with poor nutritional status. By means of integrating knowledge from nursing, other disciplines,
previous experiences and information gathered from clients and families as well as recent dietary
history, Nurses should recognize signs of poor nutrition.
Assessment of the Affecting Factors
Physical factors
Physiological factors
Age different age groups such as infants, children, adolescents, young and middle~aged adults
and older adults have varying requirements of specific nutrients. If these age-specific nutrient
needs are not met, growth and development may be severely retarded or serious health problems
may develop.
Physical activity Physical activity is a major factor effecting energy requirements. In general,
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the heavier the weight of the body parts you move in your activity and the longer time you invest,
the more calories you spend.
Special life cycle status Though all people need the same nutrients, the amounts they need
changes as they move through life. Pregnancy is one of the most important life stages. The
nutrition demands of pregnancy are extraordinary because the growth of a new person requires all
the nutrients, and extra amounts of many of them. The eating habits of a pregnant can also affect
the nutritional status of the growing fetus and herself.
Pathological factors
Major deviations from or threats to health usually create specific nutritional needs and
serious nutritional problems if the needs are not met. Serious and chronic illnesses, surgery and
injury are some of the health-related factors influencing nutritional needs of patients.
In addition, food allergies can influence the intake and absorb of nutrients.
psychological factors
Psychological stress creates the same generalized stress response as physical stress. Therefore,
prolonged emotional stress can deplete protein stores and lower immunity by reductions in
proteins available for antibody and white blood cell production. Loss of appetite may make
replacement of protein stores difficult.
Sociocultural factors
Economic Situation Economic Situation affects the food-purchasing power. For many people,
malnutrition is a serious problem.
Lifestyle Lifestyle influences what one eats, where one eats, with whom one eats, whether one
cooks for oneself, how frequently food purchases are made, and how much time is allowed for
eating. Drug and alcohol abuse significantly damages a person's nutritional status. Drugs,
including tobacco, disturb appetite and can either raise or lower the basal metabolic rate. Alcohol
abuse causes serious long-term nutritional effects and potentially fatal liver disease.
Personal Preference Many people make conscious decisions regarding how and what they will
eat on the basis of their personal philosophy, beliefs, and values. Vegetarianism is an example.
Nurses must understand the many different forms a vegetarian diet may take and the nutritional
implications.
Knowledge About Nutrition Many people may base their food habits on beliefs acquired
through competitive product advertising, peer groups, or family and cultural traditions, rather than
expert information.
Extremes in dietary habits or food fads can lead to severe nutrient deficiencies. Individuals
with severe or chronic health problems are particularly vulnerable to promises of instant cures, as
are adolescents or young adults who are dissatisfied with their bodies.
The best defense against food faddism is an informed consumer. The Internet offers
numerous resources for nutritional education, diet analysis, consumer information, and
information about nutrition-related topics, such as obesity and eating disorders. Individuals who
understand basic nutritional principles should be able to make choices that are personally
satisfying and nutritionally appropriate.
Assessment of Diets status
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eating patterns Include data about the client's eating habits, food preferences, allergies, and so
on.
Changes in appetite
Influencing factors If there is difficulty in eating (e g, impaired chewing or swallowing)
assessment of physical status
Physical Examination
Physical examination reveals nutritional deficiencies and excesses except for obvious weight
changes. Assessment focuses on rapidly proliferating tissues such as skin, hair, nail, eyes and
mucosa. Clinical signs associated with malnutrition are provided in Table 10-1.
Table 10-1
Clinical Signs of Malnutrition
Area of Examination
Signs of Malnutrition
General appearance and vitality
Weight
Skin
Apathetic, look tired, easily fatigued
Overweight or underweight
Dry, flaky or scaly; pale or pigmented; lack of
subcutaneous fat
Brittle, pale, ridged or spoon-shaped
Dry, dull, sparse, loss of color, brittle
Pale or red conjunctiva, dryness, soft cornea, dull cornea
Swollen, red cracks at side of mouth
Swollen, beefy red or magenta colored; smooth
appearance; decrease or increase in size
Spongy, swollen, inflamed; bleed easily
Underdeveloped, wasted, soft
Anorexia, indigestion, diarrhea, constipation
Nails
Hair
Eyes
Lips
Tongue
Gums
Muscles
Gastrointestinal system
Anthropometric Measurements
Height and weight
Accurate assessment of the client's height, current body weight (CBW) and ideal body weight
(IBW) is essential. IBW provides an estimate of what a person should weight.
The standard of IBW
IBW (kg) = [height(cm) –100] ×0.9
IBW (kg) = height(cm) –105
Calculating percent of weight loss or gain
IBW－CBW
%weight loss ＝
×100%
IBW
CBW－IBW
%weight gain ＝
×100%
IBW
The normal weight is in the range of IBW± 10 % (IBW).
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Body Mass Index (BMI) body mass index, which defines average relative weight for height in
2
people older than 20 years.BMI=weight(kg) / height(m )
Example:
A 1.7m person weighing 65kg has a BMI of 22.49
BMI=65 / (1.7)2 =22.49The normal range for men is 20~25; for women is 19~24;
for eastern adults: 18.5~22.99.overweight :25~29.9; for easterner :23~24.99obesity: ≥30; for
easterner: ≥25.The BMI values have two major drawbacks: they fail to indicate how much of the
weight is fat and where that fat is located.
skinfold (fatfold) A skinfold measurement is performed to determine fat stores. It is measured in
millimeters using special calipers. The most common site for skinfold measurement is the triceps
skinfold. Changes in anthropometric measurements often occur slowly and reflect chronic changes
in nutritional status.
Laboratory Test
Laboratory tests provide objective data to the nutritional assessments. Factors that may
change test results include fluid balance, kidney function, liver function and the presence of
disease. Common laboratory tests used to study nutrition status include measures of serum
proteins, urinary urea nitrogen and creatinine and total lymphocyte count.
Serum Proteins Serum protein levels provide an estimate of visceral protein stores. Tests
usually include hemoglobin albumin, transferring, prealbumin and total iron-binding capacity. A
low hemoglobin level may be evidence of iron deficiency anemia. Albumin that accounts for over
50 percent of the total serum proteins is one of the most common visceral proteins evaluated as
part of the nutritional assessment. Albumin changes slowly. So, a low serum albumin level
indicates prolonged protein depletion rather than acute changes in nutritional status. Many
conditions besides malnutrition can depress albumin concentration, such as losses from open
wounds and burns, altered liver function. Transferring is likely to respond more quickly to protein
depletion than albumin. Transferring levels below normal indicate protein loss, hepatitis, iron
deficiency, pregnancy and liver dysfunction. Prealbumin is the most responsive serum protein to
rapid changes in nutritional status.
Urinary Tests Urea nitrogen urea and urinary creatinine are measures of protein catabolism and
the state of nitrogen balance. Urea nitrogen concentrations in the blood and urine, therefore,
directly reflect the intake and breakdown of dietary protein. Urinary creatinine reflects a person's
total muscle mass because creatinine is the major product of the creatine produced when energy is
released during skeletal muscle metabolism. Urinary creatinine is also influenced by protein intake,
age, exercise, renal function and thyroid function.
Total Lymphocyte Count Certain nutrient deficiencies can depress the immune system. The
total number of lymphocytes decreases as protein depletion occurs.
Section 4
Diet nursing
According to nutritional assessment of clients, Nurses determine existence of actual or
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potential nutrition problems and then take steps to change.
Nursing interventions to promote optimal nutrition for clients are often provided in
collaboration with physician who writes the diet orders. The nurse reinforces this instruction and
provides assistance with eating, monitors the client's appetite and food intake, administers enteral
and parenteral feedings and consults with the physician about nutritional problems that arise. The
nurse's role in the community setting and the home setting is educational. Nurses offer instructions
and counseling about nutrition. Nurses must help clients integrate diet changes into their lifestyles
and provide strategies to motivate them to change their eating habits.
During nutrition nursing, close contacting with clients and their families enables nurses to
make observations about physical status, food intake, weight changes and response to therapy.
diet administer in ward
Arrange the client's diet according to the diet orders written by physician.
Diet nursing
Diet education
Nurses are in a key position to educate clients about good nutrition habits. Outpatient and
community settings are optimal locations for nursing assessment of nutritional practices and status.
Nurses' role as educator .includes educating families and providing information about community
resources. Meal planning must consider the family's budget and different preferences of family.
members. The contents of menus need checked by a nurse or dietitian. Food safety is also an
important public health issue. Nurses should recognize the factors related to food safety.
Stimulating the Appetite
Clients often have poor appetites. Increasing a person's appetite requires determining the
reason for the lack of appetite and then dealing with the problem. Some nursing interventions that
may improve client's appetites are:
· Relieving illness symptoms that depress appetite prior to mealtime
· Providing familiar food that the client likes (clients are pleased to bring food from home
but may need some guidance about special diet requirements)
· Avoiding unpleasant or uncomfortable treatments immediately before or after a meal
· Providing a tidy, clean environment
· Encouraging or providing oral hygiene for clients before mealtime
· Reducing psychological stress, for example depression and anxiety
Assisting Clients With Meals
Because clients are often confined to their beds, meals are often brought to the client. The
interventions include:
· Prior to mealtime, determine if clients need to urinate or defecate. Assist him or her to the
bathroom or onto a bedpan. Offer the client assistance with hand washing and oral hygiene
· Assist the client to a comfortable position in bed or in a chair, which is appropriate
· Overbed tables are often prepared for clients sitting in bed or on bedside chairs
· Check the type of diet. Do not give an incorrect diet for clients
· Assist clients who cannot help themselves to remove the food and to be eaten
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· For a blind client, identify the placement of food as you would describe the time on a
clock. For example, the rice is at 6 0' clock, the soup at12 o'clock, the green vegetables at 9 and 3
0' clock. See Figure 10-1.
· After the client has completed the meal, replace the food covers and note how much and
what the client has eaten and the amount of fluid taken. If the client's intake and output of fluid is
being recorded, nurse should record.
· After the client has completed the meal, give the client care such as washing hands, and
oral hygiene.
· If the client is not eating, notify the responsible nurse so that the diet can be changed or
other nursing measures can be taken. Nurses should pay attention to the fasting client especially
on shift.
soup (12 o'clock)
vegetables (9 o'clock)
vegetables (3 o'clock)
rice (6 o'clock)
Figure 10-1 Food place ichnography fou blands
Section 5
Special diet nursing
Clients who receive only IV fluids for more than 7 days are at nutritional risk. Nutritional
problems often occur in conditions such as infection, cancer, eating disorders, gastrointestinal
disease, critical illness, metabolic diseases, renal disease and liver diseases, pancreatitis and
cholecystitis. So these clients need special diet.
Enteral Nutrition (EN)
EN refers to nutrients given via the GI tract. It is a safe and economical nutrition support. If
the client's GI tract is functioning, EN is the best method of meeting nutritional needs. Gastric
feedings may be given to clients with a low risk of aspiration. If there is a risk of aspiration,
jejunal feeding is preferred. EN has been used successfully within 24 to 48 hours after surgery or
trauma to provide fluids, electrolytes and nutritional support. EN can reduce sepsis, blunt the
hypermetabolic response to trauma and maintain intestinal structure and function. Tube feeding is
the common method of EN.
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Tube feeding
Nasogastric gavage
Nasogastric gavage is a medical approach to maintain clients' nutrition and-ensure treatment by
inserting a tube to gastrointestinal duct via nasal cavity, through which fluid food, water, and
medicine are infused.
Indications
1. Clients unable to eat by mouth, such as coma, oral diseases.
2. Premature and terminally ill clIents.
Contraindications
1. Gastroesophageal varication
2. Esophagus obstruction and esophagus cancer
Equipment
Sterile pack for nasogastric gavage
·
·
·
·
Gastric tube or silica gel· gastric tube
Tongue blade
50ml syringe
Forceps
· Sterile bowl
· Gauze
· Towel
Tray
·
·
·
·
·
·
Paraffin oil
Sterile cotton swab
Warm water
Toilet paper
Turpentine oil
Adhesive tape
· Clamp
· Stethoscope
· Pin
· Kidney tray
· Nasogastric solution (38°C-40°C)
· Gargle and equipment for mouth care
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Procedures and key Points
Steps
Rationale and Key Point
Inserting a Nasogastric Tube
1. Wash hands and wear mask
2. Prepare the equipment and take them to the
client
3. Check the client's bed number and name
according to the physician's order
4. Explain the purpose and procedure to the
client
5. Assist the client to fowler position. If the
client can't take fowler position, nurses should
assist the client to right side-lying position
6. Place towel across the client' s chest and
place kidney tray beneath the client's mandible
7. Ask the client to breath through one nostril
while occluding the other, and select the
nostril through which air flows more easily,
clean the nostril with sterile cotton swab
8. Prepare adhesive tape 8cm long
9. Open the sterile pack for nasogastric
gavage, hold the tube with gauze and forceps,
and inject little air into the tube by syringe
10. Measure length of tube to be inserted and
mark.. Measure the distance from the tip
of· the client's nose to earlobe and from
earlobe to the tip of sternum
11. Lubricate the tip of the tube with paraffin
oil, clamp end of the tube by forceps
12. Hold the tube by gauze with left hand,
clamp the tube by forceps with right hand, and
insert the tube into the selected nostril
13. Insert the tube 10-15cm and ask the client
to swallow it
14.Explain
the
importance
of
mouth· breathing and swallowing to the client
15. Advance tube with client's each swallow
until desired length has been passed into, don't
force tube against resistance
16. If resistance is met or the client starts to
cough, choke, or become cyanotic, stop
· Reduce clients' anxiety and make clients
understood the procedure
· Fowler position can alleviate vomit reflex
when gastric tube' passes the nasopharynx, and
make the tube inserted easily. If the client
vomits, this position can protect against
aspiration
· Prevent soiling of clothes
· Assess the client's nares
· Fix the gastric tube
· Check the tube unobstructed or not
· Measurement ensures that the inserted tube
will be long enough to enter the client's
stomach. Generally the length is 45-55cm
· Paraffin oil reduces friction
· Procedure should be gentle and slow
· Swallowing let the tube into esophagus
· Alleviates the client's fears during the
procedure
· Reduce discomfort and avoid trauma to the
client
· The tube is not in the esophagus if the client
shows these symptoms and signs
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advancing the tube and withdraw it, wait for a
while and then insert the tube again
17. Inspect the throat by looking into the
mouth with flashlight and tongue blade, and
determine whether the tube is coiled
18. Determine that the tube is in the client' s
stomach:
(l)Aspirate gastric contents with a syringe
(2) Quickly inject 10ml air into the tube, hear
the sound of air through water at left superior
abdomen with stethoscope
(3)Put the end of tube in water, observe no air
out
19. For coma clients: remove pillow and let
the client's head back. When the tube is
inserted 15cm, elevate client's head with left
hand and insert the tube slowly with right
hand
20. Secure the tube by fixing it to the bridge of
the client's nose and cheek with adhesive tape
Tube feeding
1. Connect syringe with the end of tube, and
aspirate first. If gastric contents are aspirated,
inject some warm water into the gastric tube
2. Feed the formula slowly as the physician's
order
3. Irrigate tube with a little warm water after
feeding
4. Fold the end of the tube, cover with gauze.
Using pin to secure the tube to bed sheet,
pillow or client's collar
5. Provide the client with oral hygiene,
remove the equipment and make bed, and ask
the client to keep the former position for
20-30min
6. Wash hands and document all relevant
· Tube may be coiled, kinked or entered
trachea
· Reduce risk of tube entering trachea
· It is easy for tube to pass through epiglottis
· Prevent the tube from pulling out
· Determine the tube in the stomach, and find
out whether there are gastric retention and tube
obstruction or not
· Warm water may wet the tube wall, and
prevent foods from adhering to the tube wall
· The amount of tube feeding does not exceed
200ml once. Interval is not less than 2h
· Tablet should be grinded and dissolved
· Avoid irrigating rate too rapid, avoid the
formula too cool or too hot
· Prevent injecting air
· Fresh juice and milk is irrigated respectively,
and this can avoid clotting
· Irrigating with warm water clears tube
feedings and reduces bacterial growth
· Prevent tube feeding leakage
· Prevent gastric tube from pulling out
· Oral hygiene keeps mouth clean and moist
and promotes comfort
· Prevent vomiting
·
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Handwashing
deters
the
spread
of
information
Removing a Nasogastric Tube
1. Place kidney tray under the client's
mandible, clamp the end of tube and put it in
the tray. Remove the adhesive tape gently
2. Ask the client to take a deep breath,
withdraw tube as the client exhales. Quickly
remove the tube when it passes throat
3. Put gastric tube in the tray and move it out
of the line of client's sight
4. Provide mouthwash if desired, and rub off
the adhesive tape trace. Assist client to gargle,
take comfortable position, clean up bed units
and remove all equipment
5. Wash hands and document relevant
information
microorganisms
· Document the type, amounts of the formula,
and client responses
· Apply to stop nasogastric diet or to change
the gastric tube
· Prevent drainage of gastric contents in tube
· This closes the glottis, thereby preventing
accidental aspiration of any gastric contents
·
This can prevent the spread of
microorganisms from the tube to other articles
or clients, and make the client comfortable
· Keep clients clean
· Use gasoline or turpentine to rub off the
adhesive tape trace
· Document removal time and the client's
responses
Elemental diets
Elemental diet is a purified food whose chemical composition is definite and it contains all
the required nutrients of human body. Its main characteristic is to provide the energy and the
nutrients to the human body directly without digest and absorb by the intestinal tract. It has been
used by the patients with severe burn and trauma, digestive tract, the nutritional support of
pre-operation and post-operation, non-infectious diarrhea, malabsorption and malnutrition.
Purpose
Elemental diet could achieve the therapeutic and adjunctive therapy effect for the severely ill
patients by ensuring the intake of energy and amino acids and promoting the wound healing.
Classification
Elemental diet can be classified as nutritional therapy diet and special therapy diet.
Administration
fractional infusion
intermittent infusion
continuous infusion.
Complications
Mechanical complications
Infectious complications
Gastrointestinal tract complications
Metabolic complications
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Table 10-2
EN Complications and Measures
Complications
Pulmonary aspiration
Diarrhea
Constipation
Tube occlusion
Main Interventions
· Check tube placement before feeding
· Elevate head of bed 30 to 45° during feeding and for 2
hours afterwards
· Deliver formula continuously, lower rate or change EN
· Don't hang formula longer than 4-8h in bag
· Check for pancreatic insufficiency, use low-fat,
lactose-free formula and continuous feedings
· Select a formula containing fiber
· Monitor client's ability to ambulate and collaborate with
physician for activity order
· Irrigate with 20ml warm water before and after each
medication
· Read pharmacological information on formula
· Shake cans well before administering
Notes to nursing
· It should be initially offered in a small amount and can be increased gradually at a low and
slow pace when patients are tolerated well then stabilize the prescription, dosage and transfusion
rate.
· Follow sterile procedure and prevent contamination.
· Prepared feedings should be stored in refrigerator below 4°C and should be used up in less
than 24h.
· The infusion temperature is 41°C-42°C, and take it orally in 37°C.
· Nurses should irrigate the tube with warm water before and after infusion, which prevent
tube from obstruction.
· nurses should observe the client's response during feeding. When clients have some
symptoms such as nausea, vomit, abdominal distention, and diarrhea, nurses should find the
reason, adjust infusion rate and temperature, and stop infusion for severe clients.
· Clients need some necessary lab tests such as blood glucose, urine glucose, blood urea
nitrogen, electrolyte. Nurses should observe clients' urine and stool, record client's weight, and
monitor 24h intake and output.
· The feedings is stopped gradually to prevent hypoglycemia.
Parenteral Nutrition (PN)
PN also referred to as total parenteral nutrition (TPN). PN is provided when the
gastrointestinal tract is nonfunctional. PN is administered intravenously through a central venous
catheter into the superior vena cava. Clients who accept PN therapy include those with severe
malnutrition, severe burns, bowel disease disorder, acute renal failure, hepatic failure, cancer or
major surgeries where nothing may be taken by mouth for more than 5 days. TPN solutions are a
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mixture of 10%-50% dextrose in water, amino acids and special additives such as vitamins,
minerals and trace elements. Before beginning an infusion, the nurse verifies the solution prepared
by the physician's order. An infusion bump is used to administer PN. Because TPN solutions are
high in glucose, infusions are started gradually to prevent hyperglycemia. The solution is started at
40-60ml/h and gradually advanced over several hours or a day to the goal rate. Most clients
receive the PN over 24 hours. Nursing care for the client's receiving PN is based on three major
nursing goals: (a) preventing infection; (b)maintaining the PN system; (c) preventing
complications such as metabolic, electrolyte or fluid balance.
Nursing for client having catheterization and catheter
· Explain the purpose and methods to the client and his family members to get their
understanding and collaboration.
· Prepare equipment for puncturing and cleaning local skin.
· Follow sterile procedure and prevent contamination.
· Tell the client not to breath deeply in the process of puncture.
· Fix the inserted catheter and prevent from being drawn out.
· Keep the puncture site dry and change dressing every day.
· Attach the vein catheter firmly to infusion catheter and cover the connection with sterilized
dressing.
· Forbid blood transfusion hemospasia, and center vein pressure monitoring through nutrition
catheter.
· Prevent the catheter from being blocked. When infusion is over, nurses should use heparin to
flush the vein catheter.
Observation and nursing during infusion
· Keep regular rate of infusion and avoid abrupt change.
· Observe infusion carefully to avoid catheter being twisted or, blocked.
· Avoid empty infusion bottle and air embolus.
· When clients have some symptoms such as nausea, perspiration, chest distress and
hyperthermia, nurses should find the reason and report to the doctor.
Monitoring
· Monitor blood glucose, urine glucose, electrolyte, liver and kidney function
· Assess client's nutrition condition.
Prevention of complications and nursing of client with complications
a. Complications related to catheterization Pneumothorax, hemothorax, air embolus, brachial
plexus damage, twisted or broken catheter. Nurses should be familiar with the anatomy of the
puncture site, master the inserting technique, and monitor infusion from time to time for anything
abnormal.
b. Infection It is the most severe complications during TPN. Severe infection can lead to
septicemia. When the client is found to have a sudden fever without inducement, nurses should
change the infusion tube and formula immediately, meanwhile, take blood and formula samples
for bacterial cultures. If the fever remains, nurses should pull out catheter, change the puncture site,
and cut a small section of catheter for culture, which may be used as reference to administer
antibiotics.
c. Metabolic complications A long-term TPN therapy may cause some metabolic
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complications as hyperglycemia, hypoglycemia, abnormal metabolism of fat and amino acids,
fluid and electrolyte imbalance, trace element deficiencies, among which hyperglycemia and
hypoglycemia are the most severe.
· Prevention of hyperglycemia and nursing of client with hyperglycemia
Prevention: Increase TPN infusion rates gradually. In case of a high-glucose infusion, additional
insulin may be administered according to the blood glucose and urine glucose. 10 % intralipid
solution that can meet part of the energy requirement can be used to reduce glucose dosage.
Treatment: Once hyperglycemia occurs, 5 % glucose injection should be immediately
Administered with insulin added into it, insulin should be added, and the component of formula
and infusion rate should be adjusted too.
· Prevention of hypoglycemia and nursing of client with hypoglycemia
Prevention: Do not discontinue or slow down infusion abruptly, and adjust additional insulin
dosage according to blood glucose and urine glucose.
Treatment: Stop additional insulin immediately and administer 50% glucose injection 50-100ml
to severe clients , and give sweet water and candy to clients who are not severe.
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