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Slide 1 ___________________________________

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Principles of
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Nutrition
and ___________________________________
Bowel ___________________________________
Elimination
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Pam Bellefeuille
RN MN APRN-BC CNS CEN
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All rights reserved pamb 709

Slide 2 ___________________________________
• Content Topics:
___________________________________
• GI/Nutrition/Elimination ___________________________________
assessments
• Assessment and Care of NG ___________________________________
tubes Feeding Tubes
Central Lines ___________________________________
• PPN/TPN
• Bowel Diversions/ Ostomies ___________________________________
___________________________________

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

Slide 5 ___________________________________
Assessment: Mrs. H’s LABS ___________________________________
• Na146 (135-145) ___________________________________
• K3.5 (3.5-5.0)
• Hgb12 (14-18) ___________________________________
• HCT 38 (40-52)
• WBC10,000 (5,000-10,000)
___________________________________
• Albumin2.4 (3.5-5) ___________________________________
• Prealbumin10 (15-36)
• Bldgluc80 (70-110) ___________________________________

Slide 6 ___________________________________
Assessment: Nutrition
___________________________________
• Recent weight loss? ___________________________________
• Change in appetite or diet recently?
• GI symptoms such as nausea, vomiting, ___________________________________
diarrhea, constipation, anorexia?
___________________________________
• Energy level changed?
• Current medical issues? ___________________________________
• Medications; prescription/OTC/other?
___________________________________
Slide 7 ___________________________________
Assessment: Nutrition
___________________________________
• Assessfor :
___________________________________
Hydration/intake/I&O
Diet/NPO/Tube Feed/ ___________________________________
TPN/PPN
Abdominal distention/ascites ___________________________________
Nutritional status/
de-conditioning/wasting, ___________________________________
Mobility/Immobility
___________________________________

Slide 8 ___________________________________
Assessment : Bowel Elimination
___________________________________
Basic Concept:
“Everybody Poops”
___________________________________
• Last Bowel Movement ___________________________________
(BM)
• Bowel Sounds; ___________________________________
Passing Flatus/Stool
• Bowel habits ___________________________________
• Rectal bleeding
___________________________________
• Meds

Slide 9 ___________________________________
MD Orders ___________________________________
• NPO
• Insert NG; NG to low intermittent suction
___________________________________
• IV D5NS at 125/hr ___________________________________
• Hydrocortisone 100 mg IV daily
• Morphine Sulfate 2 mg IV for pain now ___________________________________
• PCA orders per Pain Team
___________________________________
• Consult CNS for central line access
• Consult Nutrition Team for PPN/TPN ___________________________________
Slide 10 ___________________________________
Nasogastric tube (NGT)
___________________________________
• NGT (nasogastric tube) FT
___________________________________
removes gastric secretions NGT
with intermittent or ___________________________________
continuous suction
OR ___________________________________
• NGT without suction can
be used for meds and/or ___________________________________
short term enteral
nutrition (<2wks)
___________________________________

Slide 11 ___________________________________
According to the Metheny article,
which assessment technique is the ___________________________________
most reliable for verifying NG tube
placement? ___________________________________
• A. Auscultate over the gastric area while
injecting 30ml of air into the NG tube
___________________________________
• B. Observe the back of the throat for ___________________________________
curling of the tube
• C. Place the distal end of the NG tube in ___________________________________
water and assess for bubbling
• D. Aspirate gastric contents and test ph ___________________________________

Slide 12 ___________________________________
Nasogastric tube(NGT)
___________________________________
Priority to confirm placement :
x-ray ___________________________________
pH (<6) with color of
contents ___________________________________
measure to distal end
• Maintain patency: 30 ml. NS flush; ___________________________________
properly crush/
dissolve meds ___________________________________
• Assess electrolytes;
hydration/nutrition/elimination ___________________________________
Slide 13 ___________________________________
Central Lines
Triple lumen subclavian ___________________________________
• Peripherally Inserted Central
Catheter (PICC)/ Subclavian ___________________________________
Line(single, double or triple
lumen)
___________________________________
• Confirm placement
• Assess/Maintain patency ___________________________________
per standard flush
• Use aseptic sterile technique ___________________________________
• Assess for sepis; air “Central” Line PICC

embolism ___________________________________

Slide 14 ___________________________________
PPN/TPN : Peripheral and
Total Parenteral Nutrition ___________________________________
• PPN: short term, peripheral ___________________________________
or central line, <10% dextrose
solution NGT
___________________________________
TPN: long term; PO

central line only; complete TPN


___________________________________
nutrition; lipids needed once a
week, >25%dextrose ___________________________________
solution
Monitor blood glucose PPN
GT
___________________________________
FT JT
Taper up and taper down

Slide 15 ___________________________________
Enteral Feeding Tubes
(if the “gut” is working) ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Slide 16 ___________________________________

MrsH calls the nurse, c/o acute onset of severe


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

Slide 17 ___________________________________
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___________________________________
___________________________________
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Slide 18 ___________________________________
Intestinal Diversions :
Ostomies ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
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Slide 19 ___________________________________
Intestinal Diversions :
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Ostomies
• Ileostomy vs Colostomy ___________________________________
• Monitor nutrition ,
electrolytes, hydration ___________________________________
• Effluent drainage/ skin
integrity
• Self care issues ___________________________________
• Body image issues (self
and family) ___________________________________
• Collaborate with ETRN
(enterostomal RN) ___________________________________