There are three parts to this section:
1 Feeding a dependent patient
2 Enteral feeding
3 Parenteral nutrition
1. FEEDING A DEPENDENT PATIENT
Learning outcomes
By the end of this section, you should know how to:
▪ prepare the patient for this nursing practice
▪ collect and prepare the equipment
▪ carry out the feeding of a dependent patient.
Background knowledge required
Revision of the anatomy and physiology of the mouth and oesophagus, with special reference to the physical acts of mastication and swallowing.
Indications and rationale for the feeding of a dependent patient
The nurse may be required to feed a dependent patient to maintain adequate nutrition in:
▪ a patient who is unable to use his or her upper limbs because of paralysis or serious illness
▪ a patient who has lost upper limb co-ordination because of a physical or mental disease
▪ a patient who has recently lost his or her eyesight
▪ a patient who has an injury around the mouth.
Equipment1. Feeding utensils such as a fork, knife, spoon, drinking cup with a spout or cup with an angled straw
2. A cloth, disposable napkin or paper towel
3. Diet, as ordered by the patient
4. Trolley or tray for equipment
5. Receptacle for soiled disposable items.
In hospital or at home, this practice may be undertaken by the patient’s relatives or carers.
▪ explain the nursing practice to the patient to gain consent and co-operation
▪ collect and prepare the equipment to ensure that all the equipment is available and ready for use
▪ help the patient into a comfortable position to allow easy access to the patient by the nurse and also allow the patient to maintain his or her position during the practice
▪ observe the patient throughout this activity to note any signs of distress
▪ wash the hands and put on an apron for general hygiene purposes and to reduce the risk of cross-infection
▪ for patient satisfaction and enjoyment, keep the food not being eaten at a suitable temperature
▪ remind the patient of his or her ordered menu to permit psychological preparation for the food
▪ when possible, the nurse should sit down while feeding the patient so that this is made an enjoyable social occasion
▪ ask the patient which food he or she wishes to eat first, thereby giving the patient some control over the activity
▪ offer the food to patients at a rate set by them as hurrying them while they are eating may induce nausea or vomiting
▪ to prevent gagging or choking, place the spoon or fork accurately into the patient’s mouth
▪ offer sips of fluid during the meal to aid in the mastication and swallowing of the food
▪ discontinue feeding when asked by the patient in order to prevent a feeling of distension and excessive fullness
▪ assist the patient with mouth care following the meal as this will promote dental health and may reduce the incidence of dental caries
▪ ensure that the patient is left feeling as comfortable as possible, thus maintaining the quality of this nursing practice
▪ dispose of equipment safely to reduce any health hazard
▪ document the nursing practice appropriately, monitor the after-effects and report any abnormal findings immediately, thus providing a written record and assisting in the implementation of any action should an abnormality or adverse reaction to the practice be noted
▪ in undertaking this practice, nurses are accountable for their actions, the quality of care delivered and record-keeping according to the Code of Professional Conduct: Standards for Conduct, Performance and Ethics (Nursing and Midwifery Council 2004) and Guidelines for Records and Record Keeping (Nursing and Midwifery Council 2005).
Advice on a healthy dietary intake and the benefits of such a diet should be given by the nurse to both the patient and the carers. The nurse should provide information and education on the constituents of any special diet that is required by the patient.
Information regarding the maintenance of oral health should also be given by the nurse.
2. ENTERAL FEEDING
There are two parts to this section:
A Enteral feeding via a nasogastric tube as an intermittent bolus or continuous enteral feed
B Enteral feeding via a gastrostomy/jejunostomy tube.
Learning outcomes
By the end of this section, you should know how to:
▪ prepare the patient for this nursing practice
▪ collect and prepare the equipment
▪ describe the principles of enteral feeding
▪ outline some of the problems of enteral feeding.
Background knowledge required
Revision of the anatomy and physiology of the gastrointestinal tract
Revision of the nutritional requirements of the human body.
Indications and rationale for enteral feeding
Enteral feeding is the introduction of the daily nutritional requirements, in liquid form, directly into a patient’s stomach or small intestine by means of a tube. The tube may be inserted through the nostril and passed down into the stomach, or introduced directly into the stomach or small intestine via a surgical incision made in the abdominal wall.
Enteral feeding may be performed to maintain adequate nutrition in the following circumstances:
▪ obstruction of the oesophagus, e.g. by a neoplasm
▪ loss of the swallowing reflex
▪ oesophageal fistula
▪ preoperative preparation of malnourished patients
▪ during radiotherapy treatment
▪ postoperatively for patients who have had some types of oral surgery, or oesophageal surgery
▪ some unconscious patients
▪ patients who have severe burns.
Enteral feeding can be administered in several ways. It may be given through a fine tube with its own administration set and container for the feed, or it can be channelled through a pump. Enteral feeds may also be introduced via a self-retaining tube such as a Foley’s catheter or percutaneous endoscopic gastrostomy (PEG) tube via a surgical opening in the abdominal wall into the stomach, duodenum or jejunum. The liquid feed is usually purchased ready prepared, which can greatly reduce the potential of health care-associated infection (National Institute for Clinical Excellence 2003).
2A. ENTERAL FEEDING VIA A NASOGASTRIC TUBE AS AN INTERMITTENT BOLUS OR CONTINUOUS ENTERAL FEED
Equipment
1. Enteral feeding tube and introducer
2. Lubricant, e.g. iced water or jelly
3. Hypoallergenic tape
4. Container with prepared feed
5. Enteral feed administration set
6. Intravenous infusion stand
7. Gravity or volumetric pump if required
8. Water
9. Syringe (50 ml)
10. Gallipot, syringe and pH indicator strips
11. Stethoscope
12. Receptacle for soiled disposable items.
The second syringe should be a 10 ml size if a fine-bore tube is being used or a 50 ml catheter-tip syringe for a Ryles-type tube.
Guidelines and rationale for this nursing practice
▪ explain the nursing practice to the patient to gain consent and co-operation
▪ collect and prepare the equipment for efficiency of practice
▪ help the patient into a comfortable position, ideally sitting upright (Smith et al 1999) but otherwise at an angle of 30–45° (Murray 2000)
▪ observe the patient throughout this activity to detect any signs of discomfort or distress
▪ insert the enteral feeding tube as described in ‘Gastric aspiration’ (seep. 147) and then remove the introducer or assist the qualified practitioner as requested
▪ before commencing the feed, an X-ray is necessary to confirm the position of the tube as the lumen is too narrow to allow the usual tests to be carried out and it is necessary to ascertain that the tube has been correctly positioned. If a Ryles-type tube has been used the correct positioning of the tube can be checked by flushing the tube with 20 ml of air to ensure that it is clear (Dougherty & Lister 2004). A small amount of stomach contents is then aspirated and placed in the gallipot. The pH-sensitive paper can then be dipped into it. A pH of 3 or less indicates stomach contents
▪ attach the prepared feed in the container to the infusion stand
▪ join the administration set to the container using a non-touch technique (Smith et al 1999) and allow the feed to run through to the end of the set before it is connected to the feeding tube so that as little air as possible is introduced into the patient’s stomach
▪ adjust the flow rate as required or connect to the appropriate pump and ensure the rate of flow is as prescribed so that the patient’s stomach does not become over-distended and produce feelings of nausea
▪ when intermittent bolus feeding is the method of choice, run some water through at the end of the feed to clear the tube
▪ ensure that the patient is left feeling as comfortable as possible, thus maintaining the quality of this practice
▪ record appropriately the time of commencement of feeding and the amount and type of feed given, monitor the after-effects and report any abnormal findings immediately, providing a written record and assisting in the implementation of any action should an abnormality or adverse reaction to the practice be noted
▪ in undertaking this practice, nurses are accountable for their actions, the quality of care delivered and record-keeping according to the Code of Professional Conduct: Standards for Conduct, Performance and Ethics (Nursing and Midwifery Council 2004) and Guidelines for Records and Record Keeping (Nursing and Midwifery Council 2005).
Narrow-bore tubes for continuous enteral feeding are made of silicone or polyurethane, with a diameter ranging from 1 to 3 mm. They are more comfortable for the patient than the wide-bore tube and less likely to cause ulceration, inflammation, stricture, haemorrhage and erosion of the mucosa (Woods 1998). They do, however, become blocked more easily, and it is almost impossible to clear them by aspiration.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
