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Clinical Nursing Skills

17.3 Specialized Diets

Clinical Nursing Skills17.3 Specialized Diets

Learning Objectives

By the end of this section, you will be able to:

  • Examine the standard dietary recommendations for optimal health
  • Recognize specific therapeutic diets for diseases or conditions
  • Describe consistency modification diets
  • Identify what enteral nutrition is and how to administer it
  • Understand what parenteral nutrition is and how to administer it

Sometimes dietary intake must be adapted to meet individual nutrient needs. This may include restricting or increasing specific nutrients in the diet. It may also include modifying the consistency of the food when there is impaired swallowing or a need to give rest to the digestive tract. Sometimes nutrition must be administered via alternate means, such as directly into the stomach or via a central line. Nurses must be skilled in identifying, implementing, and evaluating therapeutic diets of all types across a person’s life span and in both acute and chronic settings.

Standard Dietary Recommendations

Good nutrition is essential to healthy living. A healthy diet is key to obtaining optimal nutrition. Holistic nursing care includes routinely assessing a patient’s nutritional status and providing the patient with sound instruction and coaching regarding their dietary needs for optimal nutrition intake. This should occur in all patient care settings. Whether the patient maintains a healthy lifestyle, partakes in unhealthy dietary habits, or has a chronic illness that requires a specialized diet, nutritional health promotion must be made available to all patients. It is essential that nurses understand nutritional principles and be skilled in teaching healthy dietary habits. This section reviews the standards for a healthy diet and discusses MyPlate, an eating strategy designed by the Center for Nutrition Policy and Promotion at the USDA to simplify and standardize dietary eating patterns. Food labels and food safety concerns are also discussed.

Standards for a Healthy Diet

A healthy diet is one that meets the daily recommended intake for macronutrients and micronutrients. Based on the Healthy Eating Index, the USDA recommends the following pattern for dietary intake:

  • carbohydrates: 50 to 60 percent of calories per day with less than 10 percent added sugars
  • fat: 20 to 30 percent of calories per day with less than 10 percent saturated fat
  • protein: 10 to 20 percent of calories per day
  • fiber: 25 grams per day
  • fluids: 2.5 liters per day

The USDA recommends daily allowances for sodium, calcium, and vitamins D and B12 as well. A healthy diet must take into consideration individual caloric needs. Caloric needs are based on biological sex, age, and activity level. Some diets require strict adherence to the USDA recommendations, including calorie counting; however, the average patient will benefit from teaching related to general principles. Here are some general guidelines for healthy eating:

  • Eat a variety of foods, including plenty of vegetables, fruits, and whole grains.
  • Choose healthy proteins such as lean meats, fish, poultry, low-fat dairy products, and legumes.
  • Drink plenty of water.
  • Limit salt, alcohol, saturated and trans fats, and added sugar.
  • Eat whole foods as much as possible and avoid highly processed foods.

A healthy diet prioritizes the consumption of sufficient amounts of vegetables and fruits on a daily basis. Vegetables and fruits should be eaten whole whenever possible. There are different categories of vegetables: dark green, red and orange, beans, nuts and seeds (legumes), and starches such as potatoes and cassava. Fruits may be fresh or frozen, canned, or dried. It is best to limit fruit juices, which may be high in calories.

Whole grains are an important part of a healthy diet; they include products made from wheat, rice, or oats that have not been refined. Refined grains, such as white rice and white flour, are grain kernels that have been processed to remove the bran and germ covering of the grain. This refining process removes important nutrients, such as fiber, iron, and vitamins. Whole grains use the entire grain kernel and are more nutritious than refined grains.

Foods that are high in protein include animal products such as seafood, beef, poultry, and eggs, as well as plant-based foods such as beans, peas, seeds, and nuts. Protein choices should be lean and varied. Dairy is a good source of protein, vitamins, and minerals, but low-fat versions of milk, yogurt, and cheese are typically healthier choices. Fats should be limited to 20 to 30 percent of calories, with strict limits on saturated fats. Oils are liquid fats that provide important nutrients. Oils are classified as unsaturated, polyunsaturated, or saturated. A healthy diet will include unsaturated or polyunsaturated fats and limit saturated fats.

Dietary teaching for everyone should focus on developing consistent eating patterns that include healthy amounts of carbohydrates, proteins, fats, and plenty of fresh water. A healthy diet should limit added sugars, saturated fats, sodium, and alcohol. Due to the variety of foods available, dietary choices can easily be adapted to meet cultural, religious, or budgetary preferences.

Unfolding Case Study

Unfolding Case Study #3: Part 6

Refer back to Unfolding Case Study #3: Part 4 and Unfolding Case Study #3: Part 5 to review the patient data.

Nursing Notes 1600:
When asked about diet, patient reports eating out for most meals. She states, “I just don’t have time to cook. It’s much easier to grab a burger on the way home. I work crazy hours so by the time I get home, all I want to do is eat my burger and go to bed. No way I could cook after a work shift.”
5.
Take action: The nurse prepares to provide education about diet and healthy eating to the patient. What information should the nurse include in the teaching?
6.
Evaluate outcomes: After providing information to the patient about healthy eating, how might the nurse determine that the patient understands the teaching?

MyPlate

MyPlate (Figure 17.5) is a dietary tool developed by the USDA to help individuals maintain healthy eating patterns throughout life. MyPlate uses a 9-inch plate as a visual tool for meeting the USDA’s general guidelines. Using the MyPlate method, vegetables and fruits make up half the plate, grains make up roughly a quarter of the plate, and proteins make up the final quarter. A serving of low-fat dairy is included as well. A personalized MyPlate plan is based on age, sex, height, weight, and activity level. The MyPlate website and MyPlate app are available to identify calorie needs and provide simple planning recommendations based on individual needs.

USDA diagram showing MyPlate method: Make half your plate fruits and vegetables; Focus on whole fruits; Vary your veggies; Choose foods and beverages with less added sugars, saturated fat, and sodium; Move to low-fat or fat-free dairy milk or yogurt (or lactose-free dairy or fortified soy versions); Make half your grains whole grains; Vary your protein routine; Being active can help you prevent disease and manage your weight.
Figure 17.5 Through MyPlate, the USDA provides guidance on healthy eating to ensure individuals receive the RDA for each nutrient. (credit: “Start Simple with MyPlate” by U.S. Department of Agriculture, Public Domain)

Food Labeling

Scientists and government agencies have developed food labels to improve decision-making regarding nutrition intake. The USDA Dietary Guidelines provide recommended daily intakes based on DRIs for macronutrients, micronutrients, and fiber. Food labels report the recommended daily allowances for specific nutrients as a percent daily value per serving. A serving is not a regulated amount but rather a typical volume of food consumed. Food labels always identify the number of servings per container, the number of calories per serving, and the percent daily value per serving for specific nutrients.

Life-Stage Context

Poor Vision and Reading Labels

The food label is a tool used to educate the public about the nutritional value of a product, but what if a person cannot read the label? It is important to remember that people often develop poor vision as they age. As nurses, we should assess our patients’ vision using a Snellen chart to determine the need for a referral for further investigation by an ophthalmologist. We can educate our patients on the use of a handheld magnifier to enhance the print of nutritional labels. We can also encourage them to use the online Myplate.org feature to predetermine which foods to purchase before shopping. Many of the healthier foods such as whole fruits, vegetables, and pure animal protein do not require food labels.

Sometimes, manufacturers will choose to include daily values per container. Labels must include, but are not limited to, the following nutrients: carbohydrates, calcium, iron, potassium, vitamin D, fat, and protein. Fats are broken down into total fat, percent saturated fat, and cholesterol. Carbohydrates are broken down into total carbohydrates, fiber, total sugar, and added sugar. In general, a serving with a percent daily value of 5 percent or less for a nutrient is considered to have a low nutrient value. A serving with a percent daily value of 20 percent or more is considered to have a high nutrient value. A law passed in 2016 required food manufacturers to update their labels. Figure 17.6 details the changes.

Diagram showing how food labels have been revised: 1) The serving size now appears in larger, bold font and some serving sizes have been updated; 2) Calories are now displayed in larger, bolder font; 3) Daily Values have been updated; 4) Added sugars, vitamin D, and potassium are now listed. Manufacturers must declare the amount in addition to percent Daily Value for vitamins and minerals.
Figure 17.6 Updated food labels now list added sugars and potassium, clarify the meaning of percent daily value, and have been reformatted to improve readability. (credit: modification of work “What’s on the Nutrition Facts Label?” by U.S. Food and Drug Administration, Public Domain)

Food Safety

Food safety is an important part of healthy living. The goal of food safety is to prevent foodborne illnesses such as bacterial infections. The following organisms are the cause of most foodborne infections: Campylobacter, Salmonella, and Escherichia coli. Symptoms common to these infections are nausea, vomiting, diarrhea, abdominal pain, and fever. Public health departments have foodborne surveillance programs that include a national reporting system to track outbreaks. Salmonella, Shigella, and Listeria are organisms commonly included in the national reporting system. Shigella is a highly contagious intestinal infection. Listeria is caused by improper processing or pasteurization and is most harmful to individuals who are pregnant, older, or immunocompromised. Surveillance helps track infections and identify outbreaks for public health intervention.

Prevention is key to food safety and reducing the effects of foodborne illness. Whether food is being prepared in the home, a restaurant, or an institution, the same four principles of food safety apply:

  1. Keep hands, utensils, and surfaces clean.
  2. Separate raw meat, seafood, and eggs from other foods.
  3. Cook foods to the appropriate internal temperature.
  4. Chill cooked foods within two hours.

Healthy food practices are essential to good health. Nurses should reinforce these prevention strategies by encouraging good hygiene and appropriate food handling practices and providing resources for patient education.

Therapeutic Specific Diets

Standard dietary recommendations guide individuals to make nutritious choices, maintain a healthy weight, and reduce the risk of chronic disease. The development of chronic disease affects nutritional goals and complicates nutritional intake. For example, individuals who develop diabetes or heart disease have new nutrient demands depending on the severity of the disease. Someone with diabetes may be advised to maintain stricter calorie or carbohydrate goals, while someone with heart disease will be encouraged to pursue a low-fat, low-sodium dietary pattern. Physiological conditions, such as stroke and reflux disease, can result in difficulty swallowing (dysphagia), requiring changes in food texture. Some disease states and medications can impair nutrient absorption, requiring supplementation of nutrients. Many chronic diseases include specialized diets in the treatment plan. It is important for nurses to know the differences between these diets, know why the specialized diets are ordered, and work closely with dietitians and the clinical team to ensure optimal nutrition outcomes.

Consistent Carbohydrate Diet

Carbohydrates are often misunderstood. Many people limit carbohydrates as a means of calorie control, yet both simple and complex carbohydrates are healthy and important nutrients. There are conditions under which carbohydrates must be controlled, however. An example of a diet focused on carbohydrate control is the consistent carbohydrate diet, which is recommended as a treatment for diabetes. Diabetes is a metabolic disorder affecting the utilization of glucose by the body cells. Poor glucose utilization can lead to acute acid-base disturbances and chronic effects including immune dysfunction, cardiovascular disease, and neurovascular changes. The negative effects of diabetes can best be prevented by effective blood sugar control.

The consistent carbohydrate diet maintains the recommended amount of carbohydrates per day (40 to 60 percent of the diet) but is designed to meet metabolic goals through the consumption of consistent carbohydrates at each meal. This consistency spreads out the carbohydrates over all daily meals with the goal of maintaining steady glycemic control throughout the day, avoiding hypoglycemic and hyperglycemic blood glucose swings. This mimics the healthy body’s natural tendency toward glucose control and insulin release. The consistent carbohydrate diet limits the use of added sugars and encourages healthy carbohydrate choices at each meal. The emphasis is on controlling carbohydrates rather than calories. This diet supports healthy dietary patterns for all individuals, encouraging regular consumption of whole grains, whole fruits and vegetables, and low-fat dairy products, and avoiding added sugars and refined and processed foods.

Fat-Restricted Diet

Twenty to 30 percent of a healthy diet should include fat, an essential, energy-dense macronutrient. Unfortunately, not all fat is considered “good” fat. In general, individuals eating a healthy diet should limit saturated fat to 10 percent of calories consumed. Most saturated fat comes from animal proteins. Because fat is associated with increased risk of obesity, heart disease, hypertension, and stroke, individual treatment plans may include fat-restricted diets to limit risk or decrease disease progression.

Fat-restricted diets adhere to the same USDA recommendations for a healthy diet, which is to consume between 20 and 30 percent of calories as fat but limit the types of fat consumed by avoiding saturated and trans fats. Saturated fat is typically solid at room temperature and is high in cholesterol. High-fat meats, butter, whole milk products, and coconut oil are common saturated fats. Trans fats are artificially produced by a process called hydrogenation. Partially hydrogenated fats are found in processed foods such as cookies, crackers, and margarine spreads. For patients with heart disease or at risk for developing heart disease, the American Heart Association recommends eliminating trans fats and limiting saturated fats to 5 to 6 percent of calories consumed, which is significantly lower than the dietary standard of 10 percent. Substituting more monounsaturated and polyunsaturated fats, such as canola, olive, and corn oils, is a healthy way to obtain needed fat in the diet while reducing the risk associated with “bad” fats.

High-Fiber Diet

Dietary fiber is a type of carbohydrate that adds bulk to aid in digestion. Fiber is found in plant foods and is categorized as soluble or insoluble. A high-fiber diet is recommended for most individuals, as it improves digestive health, aids in weight control, and reduces the risk of colon cancer and other intestinal disorders. Foods high in fiber include whole fruits and vegetables, whole grains, and legumes. High-fiber foods are known to decrease risk of gastrointestinal disorders, cardiovascular disease, and many metabolic disorders and should be included in all healthy diet routines.

Low-Fiber Diet

There are a few conditions that contraindicate a high-fiber diet. Limiting the fibrous content of foods eases digestion. Medical conditions that require periods of gastrointestinal rest benefit from a short-term reduction in fiber intake. Gastrointestinal rest allows for limited stimulation and processing in the intestinal tract, and a low-fiber diet is often included in the treatment plan. Eggs, creamy nut butters, low-fiber whole grain cereals, vegetable and fruit juices, applesauce, and canned fruits and vegetables can be included in a low-fiber diet. This diet should avoid all raw or undercooked vegetables, whole grains, nuts, seeds, and fibrous meats. A low-fiber diet is often used following intestinal surgeries or radiation treatments to the abdomen. Fiber should be slowly added back into the diet as digestive health returns.

Sodium Restriction Diet

The general population should limit sodium intake to less than 2,300 mg/day. Sodium is an essential element needed for many basic physiological processes. Sodium aids in food processing as a flavor enhancer, a curing agent and preservative, and a thickening agent. It also helps regulate the moisture content of food. Because of its versatility, many processed foods are high in sodium content. Unfortunately, high sodium levels increase the risk of cardiovascular disease and hypertension and negatively impact fluid balance within the body. Therefore, sodium-restricted diets are commonly prescribed for individuals with heart disease or at risk for heart disease and chronic fluid retention.

The first step in maintaining a low-sodium diet is to eliminate processed foods from the diet. Eating whole, natural foods keeps the diet naturally low in sodium. Next, all food labels should be carefully monitored for sodium content. Products with less than 200 mg per serving are healthy choices for this diet. Eating a diet high in fresh fruits and vegetables and fresh lean meats, reading food labels, and substituting herbs and spices for added salt are important ways to maintain a low-sodium diet and manage health risks.

Kidney Diet

The kidneys regulate fluid and electrolyte balance in the body. The kidneys are made up of nephrons, which filter the blood to produce urine. A kidney diet is prescribed when kidney function becomes chronically impaired and restricting certain nutrients is necessary to preserve kidney function. Foods high in protein, sodium, and potassium are limited in a kidney diet. Protein metabolism leads to waste products that must be filtered by the kidneys; therefore, a kidney diet will limit protein (animal or plant based) to small portions (2–3 oz). Because water follows sodium in the body, high sodium in the blood can lead to excess fluid volume and increased blood pressure. Because high blood pressure adversely impacts the function of delicate nephrons, sodium restrictions are placed to help preserve kidney function. With advanced kidney disease, phosphorous and potassium are also restricted. While most people on a kidney diet should have 2,000 mL intake of fluid daily, in advanced disease fluid may be restricted even further based on individual need. Routine lab work is required to monitor kidney function, fluid status, and electrolytes.

High-Calorie, High-Protein Diet

A high-calorie, high-protein diet may be prescribed when there is a need for extra nutrition to aid healing. Individuals with extensive burns or poor healing wounds may be placed on a diet rich in quality proteins, providing needed energy and nutrients to speed healing and tissue repair. This diet minimizes carbohydrate intake and increases protein intake. Proteins with high amounts of saturated fats should be avoided. Egg whites, fish, fowl, dairy, and legumes are excellent protein choices. Avocados, cheese, nuts, and dried fruit make excellent calorie-dense snack choices. Weight trends must be closely monitored; also, because high protein levels can negatively impact kidney function, kidney labs must be routinely followed.

Consistency Modification Diets

Some diets are designed to alter the texture and consistency of foods rather than the nutritional content. Anatomical abnormalities, such as cleft palates, may prevent normal mastication. Neurological dysfunction can impede swallow reflexes. Gastroesophageal reflux disease can cause esophageal strictures that can cause dysphagia (difficulty swallowing). These conditions often require changes in food texture to improve nutritional access and decrease the risk of aspiration of food particles into the lungs. Typically, a speech pathologist will make recommendations to the clinical team regarding the need for modified diets based on the results of swallow studies. Nurses must collaborate with the whole clinical team, as they are responsible for managing the dietary intake of patients on modified diets. It is essential to understand, maintain, and monitor outcomes for all patients on modified diets.

Liquid Diet

Liquid diets are used to meet short-term clinical goals. Liquids are classified by the consistency of the fluid. Clear liquids melt to a transparent fluid that contains no pulp. A full liquid is a fluid that contains sufficient residue but still maintains a fluid form. Sometimes the consistency of liquids is restricted based on viscosity. Liquid diets are implemented for a variety of reasons and are often an essential part of the treatment plan.

Clear Liquid

A clear liquid diet is often used as short-term treatment with specific clinical goals. Clear liquids are necessary before and after certain medical procedures (including after surgery) and for patients who need to rest their bowels or replace fluid and electrolytes, for example, due to severe diarrhea. This is not a diet that can be maintained long term because it has little nutritional value. A clear liquid diet includes transparent liquids with minimal residue. This includes broths, tea, clear juices, clear gelatin, popsicles, and sport drinks. The liquids cannot contain any pulp or substance.

Clear liquids can be thickened to improve the consistency for individuals who aspirate on thin liquids. A thickening agent is added to the clear liquid to increase the viscosity, allowing for the thickened liquids to move more slowly and improve swallowing. The viscosity can be varied as needed. Common consistencies include nectar thick, honey thick, or pudding thick. Nurses often collaborate with speech pathologists when thickened liquids are being considered.

Full Liquid

A full liquid diet contains residue and is not transparent. It includes foods that become liquid at room temperature. While it contains a sufficient amount of nutrition, it can be difficult to meet daily nutritional needs and should only be used short term. Full liquid diets include cream soups, ice cream, pudding, and juices with pulp. A full liquid diet is part of the treatment plan when restarting oral feeding following a period of enteral or parenteral feeding or for short-term care when a patient is unable to tolerate a mechanical soft diet.

Soft Diets

Soft diets are diets in which the consistency and texture of the food are manipulated to improve swallowing or digestion. These diets typically contain lower fiber (less than 2 grams per serving) and a soft texture. They exclude fibrous meats, raw vegetables and fruits, beans, shellfish, and whole grains. The texture is dependent on the specific impairment. Soft diets are often used for patients with some degree of dysphagia or for postsurgical care.

Mechanical Soft

A mechanical soft diet is most often used with individuals who have a chewing or swallowing deficit. This is commonly seen in patients with dysphagia or dental impairment. The food is processed to a soft texture. Vegetables and meats should be tender, well cooked, and chopped or ground to the texture of mashed potatoes. Eggs, white rice and pasta, applesauce, and dairy products work well in a mechanical soft diet. Teaching patients to chew slowly and thoroughly and to ingest frequent small meals is helpful.

Pureed Diet

Pureed diets are processed to a smooth liquid consistency. Unlike a full liquid diet, pureed foods can come from a variety of sources, though it is best to avoid nuts and raw fruits and vegetables. It is best to puree foods separately. A pureed diet is prescribed for patients with an inability to chew and for some types of dysphagia. It is typically used for a short-term period following acute illness or injury but may be used for the long term when dysphagia cannot be resolved or when frailty or dementia limit nutritional intake at the end of life.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Assisting a Patient with Eating

See the competency checklist for Assisting a Patient with Eating. You can find the checklists on the Student resources tab of your book page on openstax.org.

Enteral Nutrition

An alternate form of nutrition, enteral nutrition, utilizes a tube or catheter for administration. Enteral feedings are liquid and come in a variety of formulas to meet specific needs. These feedings are prescribed for individuals who have lost the ability to ingest food orally but who otherwise have a functioning digestive tract, capable of absorption and digestion of nutrients. Enteral nutrition typically has two routes of administration: nasogastric (NG) tube and percutaneous enteral gastrostomy (PEG) tube. Care of the patient on enteral feedings requires the expertise of an interdisciplinary team. Nurses are integral members of the enteral nutrition team and must be skilled in the administration, management, and evaluation of nutritional status when enteral nutrition is prescribed. Figure 17.7 shows the different access points for enteral tubes.

Diagram showing different access points for enteral tubes: nasogastric tube (NGT) inserted through nasal cavity, through esophagus, stomach, and small intestine; percutaneous endoscopic gastronomy (PEG) inserted into stomach; Percutaneous endoscopic jejunostomy (PEJ) inserted into small intestine
Figure 17.7 An enteral tube can access the digestive system via the nose or the abdomen. (credit: modification of work "Figure 14.12 Enteral Tube Access" by Open Resources for Nursing (Open RN), CC BY 4.0)

Nasogastric and Orogastric Tubes

NG tubes are sometimes placed when food cannot be safely ingested. They are utilized for the short term only, typically less than four weeks. The NG tube is a single- or double-lumen tube that is passed through the nares, pharynx, and esophagus and into the stomach; it can be used for suctioning stomach contents and administering medications in addition to providing enteral nutrition. Orogastric (OG) tubes work in the same manner except they are inserted through the mouth into the esophagus and then into the stomach. OG tubes are typically used with mechanically intubated and sedated patients and should never be used in conscious patients because they can induce a gag reflex and cause vomiting.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Administering a Tube Feeding

See the competency checklist for Administering a Tube Feeding. You can find the checklists on the Student resources tab of your book page on openstax.org.

Percutaneous Enteral Gastrostomy Tube

A PEG tube is placed directly through the abdominal wall via endoscopy. The PEG tube is placed in the stomach for direct administration of formula feeds and medications. In some situations, the tube can be advanced through the gastric pouch into the proximal part of the small intestine (jejunostomy). PEG tubes and jejunostomies are utilized when alternative nutrition is needed long term. PEG tubes may also be used when there is an obstruction to the esophagus, or the esophagus has been removed. Percutaneous endoscopic jejunostomy (PEJ) tubes are inserted through the abdominal wall directly into the jejunum, bypassing the esophagus and stomach. PEJ tubes are used when all or part of the stomach has been removed or if the provider determines PEJ placement would best suit the patient’s needs.

Clinical Safety and Procedures (QSEN)

QSEN Competency: Caring for a Gastrostomy Tube

See the competency checklist for Caring for a Gastrostomy Tube. You can find the checklists on the Student resources tab of your book page on openstax.org.

Nursing Considerations for Administration

Nursing considerations for enteral nutrition involve management of care concerning placement and maintenance of the tube, administration of formula feeds and medications, and prevention and monitoring of complications. Care is dependent on the type of tube being used and the underlying medical conditions of the patient.

Real RN Stories

Communicating about NG Tube Insertion
Nurse: Rosa, BSN
Clinical setting: ICU
Years in practice: 1
Facility location: Vermont

I was caring for a patient who had been in an automobile accident where he sustained multiple injuries all over his body, including an injury to his mouth and jaw. His eyes were swollen shut, and he was rarely conscious. The last nurse attempted to insert the NG tube twice, but both times, Mr. Zhu resisted by twisting and turning his head and pulling it out with his hands. During report, my supervisor told me that in order to insert the tube, I might need to increase Mr. Zhu’s sedation or request for an order for wrist restraints. I considered all of these options and decided to try another way. I gathered the supplies and approached Mr. Zhu’s room. I knocked on the door and began talking to Mr. Zhu, even though he seemed unconscious and unaware of my presence. I told him who I was and why I was there, and I let him know where I was going to touch him to do his assessment and care. Then, I explained that he had an injury to his mouth and jaw. These injuries meant that he could not chew his food or have anything in his mouth for a while. In order to give him nutrition, he needed a tube from his nose to his stomach. This was better for him than any other option right now. I told him it would be uncomfortable but quick. Mr. Zhu did not move or indicate understanding of what I told him. However, when I began to insert the NG tube, it went in smoothly, and Mr. Zhu did not resist. Once I was finished, I thanked Mr. Zhu and told him that I had secured the tube so that it would not be pulled out and he would not have to have it reinserted again. I thanked him again and exited the room.

An NG tube can be placed by a nurse but requires a clinician’s order. Once placed, the NG tube is anchored to the nose or cheek, and the length of the external tubing is documented. Placement must be verified via x-ray imaging prior to use. A PEG tube or jejunostomy is placed by a physician via endoscopic procedure. Placement is also verified by x-ray imaging prior to use. The placement of NG and PEG tubes must be verified prior to every subsequent use, per facility protocol. The tubing is monitored for migration every shift and with every use. If placement of the tube is in question, gastric contents can be aspirated and their pH tested for appropriate acidity. Follow-up x-rays can be ordered for reevaluation of placement if needed. Incorrect placement can lead to aspiration or perforation.

The registered dietitian determines the type of formula needed following patient assessment. The nurse administers the enteral feeding as prescribed. Enteral nutrition can be administered via bolus or pump with a set volume and rate of administration. Free water flushes are commonly administered prior to and following administration or in tandem with an enteral feeding pump. Tubing should be assessed for migration and obstructions with every formula feed. The nurse should monitor for leakage and skin breakdown. The tubing should be cleansed routinely according to facility protocol, typically using water or saline and soft gauze. Any redness or purulent drainage should be documented and reported.

Enteral feedings are associated with complications. It is the nurse’s responsibility to mitigate these types of risk:

  • To reduce the risk of aspiration,
    • maintain slow, steady administration rates;
    • keep the patient’s head of bed elevated 30° to 45° as tolerated;
    • monitor for migration of visible NG/OG tubing; and
    • assess for residual gastric contents and follow facility policy for rate reduction protocols.
  • To reduce the risk of clogged tubing,
    • flush the tube with water every shift and prn (as needed),
    • flush tubes before and after administration of feedings or medication,
    • assess for any residual gastric contents and follow facility policy for rate reduction protocol, and
    • irrigate tubing per facility protocol.
  • To reduce the risk of gastric distress,
    • administer feedings at room temperature;
    • maintain prescribed rate of administration;
    • assess placement every shift and prior to feeding or medication administration; and
    • assess for signs of gastric distress including nausea, diarrhea, abdominal pain, and distension.

Parenteral Nutrition

A form of alternative nutrition is parenteral nutrition (PN), in which a nutrient formula is administered intravenously. PN has a high osmolality and causes irritation to veins, so it should always be administered through a central venous catheter. A central venous catheter provides intravenous access directly to the vena cava, which empties into the heart. PN is reserved for individuals who do not have a functional gastrointestinal tract. This includes children with congenital gastrointestinal malformations, individuals with severe ulcerative colitis or bowel obstruction, and those who are critically ill with organ failure. The formula is composed of macronutrients and micronutrients. The three major macronutrients are dextrose (a form of glucose), proteins, and fat (lipid) emulsions. Vitamins, trace minerals, and electrolytes are also added. There are two types of PN: peripheral parenteral nutrition (PPN) and total parenteral nutrition (TPN).

Types of Parenteral Nutrition

PN requires central venous access. A central venous catheter is inserted in the jugular or subclavian vein and terminates in the vena cava. Central lines can be tunneled for long-term use (months to years) or nontunneled for intermittent use. Peripherally inserted central catheter (PICC) lines are long catheters inserted through a vein in the arm. Commonly, the basilic vein is used, terminating in the superior vena cava. PICC lines are used for intermediate use, typically weeks to months. Standards of care must be followed to reduce complication rates and improve patient outcomes. Policies regarding the care and use of central lines should follow facility protocols.

Peripheral Parenteral Nutrition

PPN is administered through a PICC line using a pump. PPN is intended for short-term use, typically less than ten days. The peripheral insertion reduces risk and irritation by limiting osmolality, which can lead to higher volume per feeding. Care of the PICC line should follow standard guidelines and facility protocols.

Total Parenteral Nutrition

TPN is administered through a central venous catheter. TPN is administered when the gastrointestinal tract is not functional or when the patient needs to rest their bowels. Energy and nutrient needs are calculated based on individual need and body weight. Nutrients include amino acids, fatty acids, vitamins, minerals, and electrolytes. Carbohydrates are provided as dextrose. Lipid emulsions are often administered separately. In recent years, the use of three-in-one admixtures, which are composed of dextrose, proteins, and lipid emulsions, has improved patient care by streamlining TPN administration and reducing complications.

TPN is administered through a central line into the vena cava of the heart for long-term access. Close monitoring is required whenever a patient is receiving TPN. Weight, intake and output, and blood glucose must be monitored carefully. Bloodwork must be evaluated and documented to follow trends involving complete blood count, electrolytes and blood urea nitrogen (BUN), prealbumin, and albumin. Complications associated with TPN include central line infections, fluid volume overload, glucose and electrolyte disturbances, and liver and gallbladder dysfunction.

Nursing Considerations for Administration

Nursing considerations related to PN include catheter care, administration of parenteral nutrition (PN), preventing and responding to complications, and ongoing assessment of nutritional status. Nurses should follow these guidelines for central line care and administration of PN:

  • PICC dressings should be changed every seventy-two hours using sterile technique.
  • PN should be administered through a dedicated lumen.
  • Parenteral tubing should be changed every twenty-four hours.
  • The PN label should be verified against the documented order.

Complications associated with PN include central line infections, sepsis, poor blood sugar control, hepatic dysfunction, and fluid and electrolyte imbalance. Nursing interventions should be geared toward prevention:

  • Maintain strict sterile technique for central line care.
  • Monitor vital signs routinely.
  • Monitor blood sugar and administer insulin per protocol.
  • Assess for fluid imbalance.
  • Monitor labs for trends involving electrolytes, kidney, and liver function.
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