Nutrition and Oral Hydration: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of nutrition and oral hydration in order to:
- Assess client ability to eat (e.g., chew, swallow)
- Assess client for actual/potential specific food and medication interactions
- Consider client choices regarding meeting nutritional requirements and/or maintaining dietary restrictions, including mention of specific food items
- Monitor client hydration status (e.g., edema, signs and symptoms of dehydration)
- Initiate calorie counts for clients
- Apply knowledge of mathematics to client nutrition (e.g., body mass index [BMI])
- Manage the client's nutritional intake (e.g., adjust diet, monitor height and weight)
- Promote the client's independence in eating
- Provide/maintain special diets based on the client diagnosis/nutritional needs and cultural considerations (e.g., low sodium, high protein, calorie restrictions)
- Provide nutritional supplements as needed (e.g., high protein drinks)
- Provide client nutrition through continuous or intermittent tube feedings
- Evaluate side effects of client tube feedings and intervene, as needed (e.g., diarrhea, dehydration)
- Evaluate client intake and output and intervene as needed
- Evaluate the impact of disease/illness on nutritional status of a client
Adequate nutrition consists of the ingestion and utilization of water, essential nutrients, vitamins and minerals to maintain and sustain health and wellness.
A normal diet should consist of all of the food groups including fruits, vegetables, dairy foods, protein and grains according to the United States Department of Agriculture.
Like other basic human needs such as elimination, nutrition can be negatively impacted by a number of factors and forces such as diseases and disorders like anorexia, nausea, vomiting, anorexia, dysphagia and malabsorption, cultural and ethnical beliefs about nutrition and foods, personal preferences, level of development, lifestyle choices, economic restraints, psychological factors and disorders such as eating disorders, medications, and some treatments like radiation therapy and chemotherapy.
Some of the terms and terminology relating to nutrition and hydration that you should be familiar with include those below.
- Anabolism: Anabolism is one of the three things that occur with protein metabolism. Anabolism occurs when these cells utilize amino acids to build tissue up. The other two mechanisms of protein metabolism are catabolism and a nitrogen balance.
- Catabolism: Catabolism, which also occurs with protein metabolism, occurs when excessive amino acids are broken down in the tissue and the liver.
- Nitrogen balance: Nitrogen balance occurs as the result of the client's level of protein nutrition. It reflects protein metabolism and the gains and losses of nitrogen.
- Basal metabolism rate: The basal metabolism rate reflects the extent to which the body meets the energy demands of the body with the metabolism of food.
- Body mass index: Body mass index is an indication of how much fat there is in the body. Body mass index is used as a measurement that is useful in determining whether or not the client is overweight and/or retaining fluids or if their body mass index is acceptable for the client's height and weight.
- Calorie: A calorie is a measure of heat. The number of calories varies among the food groups. For example, there are 9 calories per gram of fat and there are 4 calories per gram of protein and carbohydrates.
- Complete protein: A complete protein is a protein that consists of all of the essential amino acids in addition to some non-essential ones. Examples of complete proteins include poultry, meats, fish and eggs.
- Incomplete protein: An incomplete protein is a protein that is without one or more of the essential amino acids. Vegetables of all kinds are considered an incomplete protein.
- Essential amino acids: Essential amino acids are those amino acids that cannot be made by the body. The nine essential amino acids include tryptophan, valine, methionine, phenylalanine, histidine, leucine, threoline, isoleucine, and lysine.
- Nonessential amino acids: Nonessential amino acids are those amino acids that can be made by the body. Examples of nonessential amino acids are cystine, glutamic acid, alanine, aspartic acid, proline, serine, hydroxyproline and tyrosine.
- Dysphagia: Dysphagia is difficulty swallowing. Dysphagia can occur as the result of an anatomical stricture and from other causes, including those that are neurological in nature.
- Fat soluble vitamins: Fat soluble vitamins are vitamins that cannot be produced by the body and those that can be stored in the body. A client can also overdose on fat soluble vitamins because they can accumulate these kinds of vitamins with this storage. Examples of fat soluble vitamins are vitamins A, D, E and K.
- Water soluble vitamins: Water soluble vitamins are vitamins that cannot be produced by the body and those that cannot be stored in the body. These vitamins are not stored in the body. Examples of water soluble vitamins are vitamins B and C.
Adequate nutrition is dependent on the client's ability to eat, chew and swallow.
In addition to a complete assessment of the client's current nutritional status, nurses also collect data that can suggest that the client is, or possibly is, at risk for nutritional deficits. The assessment of the client's nutritional status is done with a number of subjective and objective data that is collected and analyzed. For example, the client is assessed using the A, B, C and Ds of a nutritional assessment in addition to the use of some standardized tools such as the Patient Generated Subjective Global Assessment and the Nutrition Screening Inventory. The A, B, C and Ds of nutritional assessment include:
- A: Anthropometric Data: This data includes variables such as height, weight, body mass index and arm measurements such as the mid arm circumference and the triceps skin fold.
- B: Biochemical Data: Laboratory testing data like serum albumin, hemoglobin, urinary creatinine, and serum transferrin.
- C: Clinical Data: The client's skin condition, level of activity and status of the client's mucous membranes.
- D: Dietary Data: This data includes the client's subjective reports of their food and fluid intake over the last 24 hours and the types of foods that are typically eating.
Some of the factors that impact on the client's nutrition, their nutritional status and their ability to eat include:
- Level of health
- Psychological influences and disorders
- Personal preferences
- Religious practices and rituals
- Level of development
- Lifestyle choices
- Personal beliefs about food and food intake
- Therapeutic treatments
- Level of health
- Psychological influences and disorders
- Economic status
- Swallowing disorders
- Chewing disorders
Swallowing disorders, chewing disorders and poor dentition are factors that can impede the client's mechanical ability to eat. For example, a client with a chewing disorder, such as may occur secondary to damage to the trigeminal nerve which is the cranial nerve that controls the muscle of chewing, may have impaired nutrition in the same manner that these clients are at risk:
- A client with poor dentition and misfitting dentures
- A client who does not have the ability to swallow as the result of dysphagia which is a swallowing disorder that sometimes occurs among clients who are adversely affected from a cerebrovascular accident
- A client with an anatomical stricture that can be present at birth
- The client with side effects to cancer therapeutic radiation therapy
- A client with a neurological deficit that affects the client's vagus nerve and/or the hypoglossal cranial nerve which are essential for swallowing and the prevention of dangerous and life threatening aspiration
Clients with a swallowing disorder are often assessed and treated for this disorder with the collaborative efforts of the speech and language therapist, the dietitian, the nurse and other members of the health care team. Clients with poor dentition and missing teeth can be assisted by a dental professional, the nurse and the dietitian in terms of properly fitting dentures and, perhaps, a special diet that includes pureed foods and liquids that are thickened to the consistency of honey so that they can be swallowed safely and without aspiration when the client is adversely affected with a swallowing disorder.
Medications have a great impact on the client's nutritional status. Some medications interfere with the digestive process and others interact with some foods.
Some of the medications that impact on the client's nutrition status include thiazide diuretic medications which can decrease the body's ability to absorb vitamin B12 and acetylsalicylic acid which can decrease the amounts of vitamin C, potassium, amino acids, and glucose available to the body because acetylsalicylic acid can lead to the excessive excretion of these substances.
Medications, including over the counter medications, interact with foods, herbs and supplements. Some of these interactions are synergistic and others are antagonistic, that is these interactions can increase and potentiate the effects of the medication(s) and others neutralize and inhibit the therapeutic effects of the medication. For example, clients who are taking an anticoagulant such as warfarin are advised to avoid vegetables that contain vitamin K because vitamin K is the antagonist of warfarin.
Food – drug interactions will be more fully discussed in the "Pharmacological" and "Parenteral Therapies" sections in the subtitled topic "Providing Information to the Client on Common Side Effects/Adverse Effects/Potential Interactions of Medications and Informing the Client When to Notify the Primary Health Care Provider".
Considering Client Choices Regarding Meeting Nutritional Requirements and/or Maintaining Dietary Restrictions
As previously mentioned, a number of factors impact on the client, their preferences and their choices in terms of the kinds of foods that they want to eat and in terms of the quantity of food that they want to consume.
Some of these factors, as previously discussed, include gender, cultural practices and preferences, ethnic practices and preferences, spiritual and religious practices and preferences and, simply, personal preferences that have no basis in the client's spiritual, religious, cultural, or gender practices and preferences. The client may simply ask the nurse for a turkey sandwich, something that can be given to the client when it is available and it is not contraindicated according to the client's therapeutic diet.
These client choices and preferences become quite challenging indeed when the client has a dietary restriction. For example, Americans in the southern area of the United States may prefer fried foods like fried chicken instead of a healthier piece of broiled or baked chicken, however, when they are affected with high cholesterol levels, modifications in this diet must be made; similarly, when a member of the Hindu religion is a vegetarian and they lack protein, the diet of this person must also be modified. These modifications must be explored and discussed with the client; alternatives should be offered and discussed and the closer these alternative options are to the client's preferences, the greater the client's adherence to their dietary plan will be. Educating the client and family members about the modified diet and the need for this new diet in terms of the client's health status is also highly important and critical to the success of the client's dietary plan and their improved state of health and wellness.
Some of the terms and terminology relating to hydration and the client's hydration status that you should be familiar with for your NCLEX-RN examination include these below.
- Intracellular fluids: Intracellular fluids are those fluids that are within the cells of the body. Most of the bodily fluids, that is about two thirds of the total bodily fluids, are intracellular fluids.
- Extracellular fluids: Extracellular fluids are those fluids that are found outside of the cells of the body. About one third of the total bodily fluids are extracellular fluids and extracellular fluids include both intravascular fluids which are fluids contained in the vessels of the body and interstitial fluids which are fluids around the cells but neither in the vascular system or within the cells.
- Electrolytes: Electrolytes are electrically charged salts in the body. Electrolytes consist of both cations and anions.
- Cations: Cations are electrically charged electrolytes with a positive charge. Examples of cations are sodium, calcium, magnesium and potassium.
- Anions: Anions are electrically charged electrolytes with a negative charge. Examples of anions include phosphate, bicarbonate, sulfate and chloride.
- Diffusion: Diffusion is the principle of physics that establishes the fact that molecules will move, or diffuse, from an area that is more concentrated than the area that these molecules move to. Molecules will diffuse from an area of high concentration to an area of low concentration across a semipermeable membrane. Diffusion is a mechanism that attempts to create a balance on both sides of the semipermeable membrane.
- Osmosis: Osmosis is the principle of physics which states that water will move across the membrane from areas of high concentration to an area of low concentration. Osmosis is similar to diffusion but diffusion is the movement of molecules and osmosis is the movement of water from the area of high concentration to the area of lower concentration.
- Filtration: Filtration is the principle of physics that states that solutes, in combination with fluids, move across the membrane from areas of high concentration to an area of low concentration.
Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. Generally speaking fluid balance and fluid imbalances can be impacted by the client's age, body type, gender, some medications like steroids which can increase bodily fluids and diuretics which can deplete bodily fluids, some illnesses such as renal disease and diabetes mellitus, extremes in terms of environmental temperature, an increased bodily temperature, and some life style choices including those in relationship to diet and fluid intake.
The aging population as well as Infants and young children are at greatest risk for fluid imbalances and the results of these imbalances. For example, the elderly is at risk for alterations in terms of fluid imbalances because of some of the normal changes of the aging process and some of the medications that they take when they are affected with a chronic disorder such as heart failure. Some of the normal changes of the aging process that can lead to an imbalance of fluid include the aging person's loss of the thirst which, under normal circumstances, would encourage the client to drink oral fluids, decreased renal function, and the altered responses that they have in terms of fluid and electrolyte imbalances during the aging process
Infants and young children at risk for alterations in terms of fluid imbalances because of their relatively rapid respiratory rate which increases inpercernible fluid losses through the lungs, the child's relatively immature renal system, and a greater sensitivity to fluid losses such as those that occur with vomiting and diarrhea.
Women, in contrast to male clients, are at greater risk for alterations in terms of bodily fluids because they tend to have more fat, which contains less fluid, than muscle which contains more bodily fluid. Lastly, clients who are febrile and clients who are exposed to prolonged hot environmental temperatures will lose bodily fluids as the result of sweating and these unpercernable fluid losses. Sweating is a cooling off response to intrapersonal and extrapersonal hot temperatures.
Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the body. Fluid excesses are the net result of fluid gains minus fluid losses. When fluid gains, and fluid retention, is greater than fluid losses, fluid excesses occur.
Specific risk factors associated with fluid excesses include poor renal functioning, medications like corticosteroids, Cushing's syndrome, excessive sodium intake, heart failure, hepatic failure and excessive oral and/or intravenous fluids. Fluid excesses are characterized with unintended and sudden gain in terms of the client's weight, adventitious breath sounds such as crackles, tachycardia, bulging neck veins, occasional confusion, hypertension, an increase in terms of the client's central venous pressure and edema.
Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces. Edema is a sign of fluid excesses because edema occurs as the result of increases in terms of capillary permeability, decreases in terms of the osmotic pressure of the serum and increased capillary pressure. In combination, these forces push fluids into the interstitial spaces.
Edema is most often identified in the dependent extremities such as the feet and the legs; however, it can also become obvious with unusual abdominal distention and swelling. Nurses assess edema in terms of its location and severity.
Pitting edema is assessed and classified as:
- 1+ Pitting Edema: The edematous area is depressed or indented 1 cm or less
- 2+ Pitting Edema: The edematous area is depressed or indented 2 cm or less
- 3+ Pitting Edema: The edematous area is depressed or indented 3 cm or less
- 4+ Pitting Edema: The edematous area is depressed or indented 4 cm or less
- 5+ Pitting Edema: The edematous area is depressed or indented 5 cm or less
Some professional literature classifies pitting edema on a scale of 1+ to 4+ with:
- 1+ Pitting Edema: The edematous area is hardly detectable
- 2+ Pitting Edema: The edematous area is depressed or indented 2 cm to 4 cm
- 3+ Pitting Edema: The edematous area is depressed or indented 5 cm to 7 cm
- 4+ Pitting Edema: The edematous area is depressed or indented > 7 cm
Dehydration occurs when fluid loses are greater than fluid gains. Fluid losses occur as the result of vomiting, diarrhea, a high temperature, the presence of ketoacidosis, diuretic medications and other causes.
The signs and symptoms of mild to moderate dehydration include, among others, orthostatic hypotension, dizziness, constipation, headache, thirst, dry skin, dry mouth and oral membranes, and decreased urinary output. The signs and symptoms of severe dehydration include, among others, oliguria, anuria, renal failure, hypotension, tachycardia, tachypnea, sunken eyes, poor skin turgor, confusion, fluid and electrolyte imbalances, fever, delirium, confusion, and unconsciousness.
Significant fluid losses can result from diarrhea, vomiting and nasogastric suctioning; and abnormal losses of electrolytes and fluid and retention can result from medications, such as diuretics or corticosteroids. Clients at risk for inadequate fluid intake include those who are confused and unable to communicate their needs.
Dehydration occurs when one loses more fluid than is taken in. Fluid losses occur with normal bodily functions like urination, defecation, and perspiration and with abnormal physiological functions such as vomiting and diarrhea.
Many people on a weight reduction diet or a diet to increase their weight are based on calories counts. The number of calories per gram of protein is 4 calories, the number of calories per gram of fat is 9 calories and the number of calories per gram of carbohydrates is 4 calories.
Clients can be instructed to count calories by weighing the food that will be eaten and then multiply this weight in grams by the number of calories per gram. For example, if the client will be eating a 14 grams of plain tuna fish, the number of calories can be calculated by multiplying 14 by 4 which would be 56 calories. Similarly, a client who will be eating 100 grams of a carbohydrate could calculate the number of calories by multiplying 100 by 4 which is 400 calories.
The method above is quite cumbersome because it entails weighing the food and then calculating the number of calories. A simpler method is to read food labels. For example, if a package of frozen food like chicken nuggets states that there are 2500 calories per package and there are 3 servings in each package, each serving will have about 833 calories when a person eats 1/3 of the package of chicken nuggets.
Similar to the calculation of calories, as above, mathematics is also used to calculate other indicators about the client's nutritional status. For example, the client's body mass index (BMI) and the "ideal" bodily weight can be calculated using relatively simple mathematics.
The body mass index is calculated using the client's bodily weight in kg and the height of the client in terms of meters. The mathematical rule for calculating the client's BMI is:
BMI = kg of body weight divided by height in meters squared
So, the BMI for a client weighing 75 kg who is 1.72 meters tall is calculated as follows:
BMI = 75 kg / 2.96 = 28.8 BMI
The ideal body weight is calculated using the client's height, weight and body frame size as classified as small, medium and large. The mathematical rule for calculating this ideal weight for males and females of small, medium and large body build are:
- Ideal body weight for females with a medium body build = 100 pounds per 5 feet of height + 5 pounds for every inch over 5 feet tall for females with a medium body build
- Ideal body weight for females with a small body build = 100 pounds per 5 feet of height + 5 pounds for every inch over 5 feet tall – 10% of the client's weight for females with a small body build
- Ideal body weight for females with a large body build = 100 pounds per 5 feet of height + 5 pounds for every inch over 5 feet tall + 10% of the client's weight for females with a large body build
- Ideal body weight for males with a medium body build = 106 pounds per 5 feet of height + 6 pounds for every inch over 5 feet tall for males with a medium body build
- Ideal body weight for males with a small body build = 106 pounds per 5 feet of height + 6 pounds for every inch over 5 feet tall – 10% of the client's weight for males with a small body build
- Ideal body weight for males with a large body build = 106 pounds per 5 feet of height + 6 pounds for every inch over 5 feet tall + 10% of the client's weight for males with a large body build
Some clients need management in terms of weight reduction and others may need the assistance of the nurse and other health care providers, such as a registered dietitian, in order to gain weight. All clients, however, must have a balanced and healthy diet with all of the food groups. Fad diets and drastic weight reduction diets are not a successful way to lose and maintain a healthy weight; learning new eating habits is a successful plan for losing and maintaining a lower and healthier body weight for those clients who are overweight.
Although more clients should reduce their weight, there are some clients that have to be encouraged to gain weight. This is often the case when a client is recovering from a physical disease and disorder, particularly when this disease or disorder is accompanied with nausea, vomiting, and/or anorexia. These clients should have attractive and preferred food preferences and, at times, they may need dietary supplements and medications to stimulate their appetite.
In addition to planning a diet with the client to increase or decrease their body weight, the client's weight and body mass index should be monitored on a regular basis. The calculations for both of these variables were discussed above. In addition to these calculations, the nurse must also be knowledgeable about what is and what is not a good body mass index or BMI.
According to the U.S. Department of Health and Human Services, a body mass index of:
- < 18.5 is considered underweight
- 18.5 to 24.9 is considered a normal body weight
- 25 to 29.9 is considered overweight
- 30 to 39.9 is considered obese
- 40 is considered extremely obese
As with all activities of daily living, nurses and other members of the health care team must promote and facilitate the client's highest degree of independence that is possible in terms of their eating, as based on the client, their abilities and their weaknesses.
Some of the assistive devices that can be used to accommodate for clients' weaknesses and to promote their independent eating include items like weighted plates, scoop dishes, food guards around the plate, assistive utensils, weighted and tip proof drinking glasses and cups.
Providing and Maintaining Special Diets Based on the Client's Diagnosis/Nutritional Needs and Cultural Considerations
There are a number of therapeutic special diets that are for clients as based on their health care problem and diagnosis. All diets, including these special diets, must be modified according to the client's cultural preferences, religious beliefs and personal preferences to the greatest extent possible.
These special diets, some of the indications for them, and the components of each are discussed below.
Clear Fluid Diet
- Indications: Post-operative diet, prior to some diagnostic tests like a colonoscopy, bowel rest and during acute illness
- Components: Clear fluids including clear broth, juices like apple juice, water, tea, ginger ale, clear Italian ice, and Jell-O
Full Fluid Diet
- Indications: Advancement from a clear diet post operatively, and for clients with gastrointestinal disorders like gastritis
- Components: All clear fluids in addition to vegetable juice, milk, all fruit juices, yogurt and pudding
Soft Bland Low Fiber Low Residue Diet
- Indications: Advancement from a full fluids diet, problems with chewing and gastrointestinal disorders
- Components: Soft foods except those with fiber like fruits and vegetables
Mechanical Soft Diet
- Indications: Poor dentition, swallowing disorders, intestinal tract strictures and post operatively after face or neck surgery
- Components: Ground meats, mashed potatoes, clear and full fluids, and soft vegetables and fruits
Low Sodium Diet
- Indications: Renal, cardiac and liver disease
- Components: All foods with the exception of frozen and canned foods, cold cuts, smoked meats like bacon and sausage
Low Cholesterol Diet
- Indications: Cardiac disease
- Components: All food that are low in cholesterol; limited in terms of fats and meats
High Fiber Diet
- Indications: Constipation and other gastrointestinal disorders
- Components: High fiber foods like fruits, vegetables and whole grains
- Indications: Swallowing disorders
- Components: Honey consistency thickened fluids and easy to swallow ground and pureed foods
High Protein Diet
- Indications: Cachexia, wasting and during renal dialysis
- Components: Meats, eggs, fish and dairy products in addition to protein supplements
- Indications: Diabetes
- Components: Carbohydrate restrictions
Calorie Restricted Diet
- Indications: Weight reduction
- Components: A balance diet without sugars and low in terms of carbohydrates
Many clients have orders for dietary supplements including high protein drinks like Boost and Ensure. These drinks come in a variety of flavors including chocolate, vanilla and strawberry. The doctor's order for these nutritional supplements states the name of the specific nutritional supplement and the number of cans per day. Clients must be encouraged to drink these supplements as ordered and the client's flavor preference should also be considered and provided to the client whenever possible.
Enteral nutrition is given to clients when, for one reason or another, the client is not getting sufficient calories and/or nutrients with oral meals and eating. Enteral nutrition is most often used among clients who are affected with a gastrointestinal disorder, a chewing and/or swallowing disorder, or another illness or disorder such as inflammatory bowel disorder, a severe burn and anorexia as often occurs as the result of an acute illness, chemotherapy and radiation therapy. Enteral nutrition can be given on a continuous basis, on an intermittent basis, as a bolus, and also as supplementation in addition to oral feedings when the client is not getting enough oral feedings. Enteral feedings can consist of commercially prepared formulas that vary in terms of their calories, fat content, osmolality, carbohydrates and protein as well as given with regular pureed foods.
Enteral tube feedings are delivered with a number of different tubes such as a nasointestinal tube that goes to the intestine through the nose, a nasogastric tube which is placed in the stomach through the nose, a nasojejunal tube that enters the jejunum of the small intestine through the nose, a nasoduodenal tube that enters the duodenum through the nose, a jejunostomy tube that is surgically placed directly into the jejunum of the small intestine, a gastrostomy tube that is surgically placed into the stomach directly and a percutaneous endoscopic gastrostomy (PEG) tube. Naso tubes, like the nasogastric and nasoduodenal tubes, are the preferred tube because their placement is noninvasive, however, naso tubes are contraindicated when the client has a poor gag reflex and when they have a swallowing disorder because any reflux can lead to aspiration. Clients receiving these feedings should be placed in a 30 degree upright position to prevent aspiration at all times during continuous tube feedings and at this same angle for at least one hour after an intermittent tube feeding.
In addition to aspiration, some of the other complications associated with tube feedings include tube leakage, diarrhea, dehydration, nausea, vomiting, inadvertent improper placement or tube dislodgment, nasal irritation when a naso tube is used and infection at the insertion site when an ostomy tube is used for the enteral nutrition. At times, abdominal cramping and diarrhea can be prevented by slowing down the rate of the feeding. The doctor is notified when the residual volume is excessive and when the tube is not patent or properly placed.
Continuous tube feedings are typically given throughout the course of the 24 hour day. A pump, similar in terms to an intravenous infusion pump, controls the rate of the tube feeding infusion at the ordered rate. The residual volume of these feedings is aspirated, measured and recorded at least every 6 hours and the tube is flushed every 4 hours to maintain its patency.
Intermittent tube feedings are typically given every 4 to 6 hours, as ordered, and the volume of each of these intermittent feedings typically ranges from 200 to 300 mLs of the formula that is given over a brief period of time for up to one hour. The residual volume of these feedings is aspirated, measured and recorded prior to each feeding and the tube is flushed before and after each intermittent feeding with about 30 mLs of water and before and after each medication administration to insure and maintain its patency.
Bolus enteral feedings are given using a large syringe and they are typically given up to 6 times a day over the course of about 15 minutes. The volume of bolus enteral feedings is usually about 200 to 400 mLs but not over 500 mLs per feeding. Bolus tube feedings are associated with dumping syndrome which is a complication of these feedings.
Tube placement is determined by aspirating the residual and checking the pH of the aspirate and also with a radiography, and/or by auscultating the epigastric area with the stethoscope to hear air sounds when about 30 mLs of air are injected into the feeding tube. A pH > 6 indicates that the tube is improperly placed in the respiratory tract rather than the gastrointestinal tract.
In addition to measuring the client's intake and output, the nurse monitors the client for any complications, checks the incisional site relating to any signs and symptoms of irritation or infection for internally placed tubes, secures the tube to prevent inadvertent dislodgement or malpositioning, cleans the nostril and tube using a benzoin swab stick, applies a water soluble jelly just inside the nostril to prevent dryness and soreness, provides frequent mouth care, and replaces the securing tape as often as necessary.
Some of the side effects and complications associated with tube feedings, their prevention and their interventions are discussed below.
- Prevention: Maintaining the head of the bed up at 30 degrees
- Interventions: Emergency suctioning, placing the client on their side and addressing any respiratory distress
- Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate and formula when necessary
- Interventions: Slowing the rate down, changing the formula and medications to stop the diarrhea
- Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate and formula when necessary
- Interventions: Slowing the rate down, changing the formula and analgesics as indicated
- Prevention: Monitor the client for any signs and symptoms of dehydration, measure intake and output and notify the doctor of any abnormalities
- Interventions: Provide any ordered oral and/or intravenous fluids
Nausea and Vomiting
- Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate and formula when necessary
- Interventions: Slowing the rate down, changing the formula and antiemetic medications to stop the vomiting and to prevent any aspiration
- Prevention: Secure and monitor the tube
- Interventions: Notify the doctor and discontinue the tube feeding
Intake includes all foods and fluids that are consumed by the client with oral eating, intravenous fluids, and tube feedings; output is the elimination of food and fluids from the body. Some measurable outputs are urinary elimination, residual that is aspirated when the client is getting a tube feeding, wound drainage, ostomy output, and vomitus. Some outputs that are not measurable include respiratory vapors that are exhaled during the respiratory cycle and fluid losses from sweating.
Solid intake is monitored and measured in terms of ounces; liquid intake is monitored and measured in terms of mLs or ccs. Solid output is measured in terms of the number of bowel movements per day; liquid stools and diarrhea are measured in terms of mLs or ccs. Urinary output is monitored and measured in terms of mLs or ccs for toilet trained children and adults, and, in terms of diaper weights or diaper counts for neonates and infants. Emesis is monitored and measured in terms of mLs or ccs. A urinary output of less than 30 mLs or ccs per hour is considered abnormal.
Indirect evidence of intake and output, which includes losses that are not measurable, can be determined with the patient's vital signs, the signs and symptoms of fluid excesses and fluid deficits, weight gain and losses that occur in the short term, laboratory blood values and other signs and symptoms such as poor skin turgor, sunken eyeballs and orthostatic hypotension.
Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a client. For example, clients who are affected with cancer may have an impaired nutritional status as the result of anorexia related to the disease process and as the result therapeutic chemotherapy and/or radiation therapy; other clients can have an acute or permanent neurological deficit that impairs their nutritional status because they are not able to chew and/or safely swallow foods and still more may have had surgery to their face and neck, including a laryngectomy for example, or a mechanical fixation of a fractured jaw, all of which place the client at risk for nutritional status deficiencies.
The relative severity of these nutritional status deficits must be assessed and all appropriate interventions must be incorporated into the client's plan of care, in collaboration with the client, family members, the dietitian and other members of the health care team.
- Assistive Devices
- Non Pharmacological Comfort Interventions
- Nutrition and Oral Hydration (Currently here)
- Personal Hygiene
- Rest and Sleep