Lecture 4 5 - Fluid and Nutrition III IV

FOUNDATION OF NURSING
PRACTICE II
LECTURE 4 & 5 -
FLUID AND NUTRITION III & IV
Tess Wong
24/2 – 5/3/2021
Learning outcomes
◦ Apply nursing care process in the caring of clients nutritional
needs.
◦ Apply the nursing knowledge and problem solving skills to the
care of clients with nutritional needs.
◦ Describe nursing interventions to promote optimal nutrition.
◦ Discuss nursing interventions to treat clients with nutritional problems
◦ Describe techniques for assisting clients with meals, providing enteral
and parenteral nutrition for clients
◦ Safely provide enteral and parenteral nutrition for client
◦ Implement and evaluate nursing care associated with nursing
diagnoses related to nutritional problems
IMPLEMENTATION
Nursing management
Implementation
Dietitian
•Comprehensive
nutritional assessment
•Patient education Nurse
(diet)
•Order special diet •Frontlines nutritional
screening
Doctor
•Reinforces the
•Writes the diet orders nutritional therapy
 e.g. special diet, Nil •Provides assistance
per oral, intravenous with eating
fluid •Administer special
feeding
•Monitors the client’s
appetite & food intake
•Patient education
Patient (feeding)
with
nutritional
needs
Implementation
Supporting
special
nutritional
needs
Assisting
with
Parenteral
special
nutrition
diet in
hospital
Nutrition
Assisting
Enteral
clients
nutrition
with meals
Patient
education
Supporting special nutritional needs
1 Patients who have nausea
Loss of appetite; diminished sense of smell

2 & taste
3 Nil per oral (NPO)
Patients with impaired swallowing, &

4
digestion
◦ 1. Patients who have nausea

◦ Identify the cause of the nausea (e.g. anxiety; pain; treatment; disease
processes etc.)  try distraction, relaxation technique, & music therapy
◦ Keep tissues and water to rinse the month at the bedside
◦ Instruct the patient to wear loose clothing
◦ Allow the patient to eat what she finds appetizing and tolerates well
◦ Provide or assist with frequent oral hygiene
◦ 1. Patients who have nausea (con’t)

◦ Ask the patient to sit in an upright position for 30 to 45 minutes after
eating, unless contraindicated
◦ Offer small but frequent meals
◦ Recommend a dietary consultation if nausea and vomiting persist 
consider dietary supplements
◦ Assess for dehydration  intravenous fluid may be needed
◦ administer antiemetics as prescribed
2. Loss of appetite; diminished sense of smell & taste  causes:
Physical
illness
Physical Unfamiliar or
discomfort unpalatable
(e.g. pain) food
Appetite
Psycho-
Environmental
logical factor (e.g.
factor (e.g. noisy)
anxiety)
2. Loss of appetite; diminished sense of smell & taste

◦ Interventions for improving appetite
◦ Relieve illness symptoms that depress appetite before meal (e.g. pain
relieve, & allow rest for fatigue)
◦ AVOID unpleasant or uncomfortable treatments immediately before or
after a meal (e.g. diaper round & blood taking)
◦ Provide a tidy, clean environment that is free of unpleasant sights and
odors which may affect the appetite (e.g. soiled dressing, & used
bedpan)
◦ Encourage or provide oral care before mealtime  improves the
patient’s ability to taste

◦ Interventions for improving appetite (con’t)
◦ Provide familiar food that the person likes  encourage the relatives to
bring food from home with same guidance about special diet
requirements
◦ Position the person comfortably for mealtime
◦ Select small portions so as not to discourage the client
◦ Restrict liquid intake with meals to prevent gastric distention or feeling
full before the patient consumes sufficient nutrients

◦ Interventions for improving appetite (con’t)
◦ Psychological stress:
◦ A lack of understanding of therapy
◦ The anticipation of an operation (surgery)
◦ Fear of the unknown
◦ Nursing interventions:
◦ Discussing feelings (therapeutic communication)
◦ Giving information and assistance
◦ Psychological support to allay fear
3. Nil per oral (NPO)

◦ Intravenous fluid to maintain fluid and electrolyte balance for short
period of time (<3 days)
◦ Provide comfort measures for NPO patients  e.g. oral hygiene, ice
chips, rinsing mouth
◦ Schedule the procedures that required NPO order in the morning to
decrease the length of time the patient must be NPO
◦ Advise family or visitors NOT to eat or drink around the patient
4. Patients with impaired swallowing, digestion or elimination

◦ Dry mouth
◦ Advise the clients to avoid caffeine; alcohol; tobacco; & dry, bulky,
spicy, salty, or highly acidic foods
◦ Use lip moisturizer (e.g. olive oil)
◦ Encourage frequent sips of water

◦ Impaired swallowing (dysphagia)
◦ For patients at risk for dysphagia (e.g. elderly, stroke patient, patient
who has radiation therapy to the head and neck) to prevent aspiration
◦ Signs of dysphagia (history taking/inspection): coughs, chokes, or gags
while eating; complains of pain when swallowing, gurgling voice,
requires frequent oral suctioning, prolong or incomplete swallowing

◦ Normal process of oral feeding
1. Mastication (chewing) – mechanical breakdown of food
◦ The cheeks and closed lips hold food between the tooth  the tongue
mixes food with saliva to soften it  the teeth cut and grind solid foods into
smaller piece
◦ Partly voluntary & partly reflexive
2. Deglutition (swallowing) – to send the food from the mouth to the esophagus
◦ Coordinated activities of the tongue, soft palate, pharynx, esophagus and
>22 separated muscle groups
◦ Buccal phase: occur in mouth and is voluntary  the tip of the tongue
against the hard palate, and then contract the tongue to force the food
into the oropharynx
◦ Pharyngeal-esophageal phase: as food enters the pharynx and stimulates
tactile receptors there  involuntary reflex activity (controlled by the
swallowing center in medulla and lower pons)

◦ Aging effects on chewing and swallowing function
◦ Sensory change:  oral moisture, taste, and smell acuity
◦ Motor change: muscle mass and connective tissue elasticity   muscle
strength  & range of motion   the effective and efficient of chewing and
swallowing food 
◦ Risk of aspiration 

◦ Medical conditions that may contribute to chewing and swallowing
function
◦ Neurologic disease
◦ Stroke
◦ Dementia
◦ Traumatic brain injury
◦ Parkinson’s disease
◦ Rheumatoid disease
◦ Progressive systemic sclerosis
◦ Other
◦ Any tumor involving the head and neck area
◦ Radiation therapy (head and neck area)
◦ Chemotherapy
◦ Severe respiratory distress

◦ Refer speech therapist for specific and comprehensive assessment and
special diet prescription
◦ Liquid food: thin, nectar-like, honey-like and spoon-thick liquids
◦ Solid food: pureed, mechanically altered, soft and regular diet
4. Patients with impaired

swallowing, digestion or
elimination
◦ Impaired swallowing
(dysphagia) (con’t)
◦ Liquid food – thin (微杰),
nectar-like (少杰), honey-like
(中杰) and spoon-thick liquids
(特杰)
◦ Use TickenUp (凝固粉) to
change the consistency of the
liquid

◦ Decrease gastric secretions
◦ Encourage regular meal
◦ Thorough chewing
◦ Advise clients not to eat just before bedtime
◦ Avoid overeating & bending over
◦ Avoid fatty foods, chocolate, alcohol & smoking
Assisting with special diet in hospital
◦ Regular diet
◦ Clear fluid diet
◦ Liquid diet
◦ Soft diet
◦ Diet as tolerated
◦ Modified diet for diseases
◦ Modified diet for dysphagia patient
◦ Modified diet for religious
◦ Regular diet (正餐)

◦ Congee, rice, noodle or
macaroni
◦ For patients who do not have
special nutritional need
◦ Balanced standard hospital
diet
◦ ~2000Kcal/day
◦ low fat, low salt, low sugar &
high dietary fiber
◦ Clear fluid diet (清流質餐)

◦ Water, clear juice, clear soup,
& congee water  low in
dietary fiber
◦ For patient before or after
certain GI surgery or
investigation (e.g.
colonoscopy)
◦ To relieve thirst, prevent
dehydration, and minimize
stimulation of the GI tract
◦  for long term use  cause
nutrient deficiencies
◦ Liquid diet (流質餐)

◦ All foods in liquid form, e.g. milk, soup, congee, oatmeal, juice
◦ For patient with GI disturbances (e.g. diarrhea)
◦ For patient who cannot tolerate solid foods (e.g. chewing or swallowing
difficulties)
◦ For patient who has to transit between liquid and solid food (e.g. after
GI or oral surgery)
◦  for long term use  cause nutrient deficiencies
◦ Soft diet (軟餐)

◦ Easily chewed and digested
food, e.g. minced meat, soft
rice, shred vegetable, &
bread
◦ For patient who have difficulty
chewing and swallowing
◦ For patient with mild GI
problem
◦ For patient who has to transit
between liquid and solid food
◦ Diet as tolerated (DAT)

◦ This permits for client’s preference, appetite, ability to eat, and
tolerance for certain foods
◦ Nurse and patient can collaborate to choose the diet that tolerated
◦ Modified diet for diseases – calorie restricted diet

◦ e.g. 1800kcal diet
◦ For obese and DM client
◦ Need to consult dietitian to calculate the calories
◦ Usually low fat diet
◦ Modified diet for diseases –

low sodium diet (低鹽/鈉餐)
◦ For patient with hypertension
or cardiac problem
◦ Usually low fat diet
◦ Prescribed by doctor
◦ Modified diet for diseases – low purine diet (低普林餐)

◦ For gouty patient
◦ Purine will break down into uric acid after digestion
◦ Food that rich in purine  anchovies, baker’s and brewer’s yeast,
animal organs, sardines, mushrooms and gravies  uric acid
◦ Modified diet for diseases – low or high potassium diet (低/高鉀餐)

◦ Food that rich in potassium  vegetables
◦ For patient who has high or low serum potassium
◦ Modified diet for diseases –

clean diet (清潔餐)
◦ All foods are well cooked to
kill most microorganisms
◦ All utensils are disinfected
◦ The fruit with thick peel, e.g.
orange
◦ For immunosuppressed
patient, e.g. cancer or HIV
patients
◦ Modified diet for dysphagic

patient
◦ Solid food: pureed (糊餐),
mechanically altered (e.g.
minced diet 碎餐), soft and
regular diet
◦ According to the severity of
dysphagia
預設質類內容
質類備註
飯類肉類菜類
正餐正飯正肉正菜
軟肉：無骨肉, 無筋肉
軟餐正飯軟肉軟菜
軟菜：稔菜
切絲肉 /菜：建議體積 : (煮
切絲餐正飯切絲肉切絲菜前)
7mm x 7mmx 50mm
碎餐軟飯碎肉碎菜碎肉/菜：直徑4mm
粥餐粥碎肉碎菜碎肉/菜：直徑4mm
糊飯餐軟飯肉糊菜糊
全糊飯糊肉糊菜糊
糊粥餐白粥肉糊菜糊麥皮 /肉糊粥, 果糊
◦ Modified diet for religious

◦ Buddhism diet
◦ Halal diet (回教餐)
◦ Indian diet
◦ Western diet
Assisting patients with meal
◦ Assessment before providing a meal, (especially dysphagic
patients)
◦ Assess swallowing ability before feeding
◦ Assess level of consciousness; the patient must be alert
◦ Assess the patient’s gag reflex by tickling the back of the throat
◦ Have the patient produce an audible cough
◦ Have the client produce a voluntary swallow
◦ Swallowing Screening test (optional) [tutorial]
◦ Providing a meal (implementation)
1. Offer the patient assistance with hand hygiene and oral hygiene
before a meal
2. Assist the patient to a comfortable position in bed or in chair if no
contraindications
3. Assist the patient to put on the dentures as needed
4. Clear the overbed table so there is space for the meal tray
5. Place the table so the patient can reach the food
6. Check each meal tray for the patient’s name, the type of diet and
any Nil Per Oral (NPO) signage
7. Assist the patient as required (e.g. remove the food covers, pour
the water, cut the meat, & etc.)
8. After the patient has completed the meal, observe how much and
what the patient has eaten and the amount of fluid taken
9. Record the information as needed (intake & output chart)
10. If the patient having problems eating  record and report
Intake and
output (I & O)
chart [tutorial]
◦ Older patients who are weakened, with disabilities, must remain in
a back lying position or cannot use their hands  may require
assistance  oral feeding
◦ Help the patient feed themselves as much as possible

◦ General measures for oral feeding
◦ AVOID distracting environment (e.g. watching TV during mealtime)
◦ Check patient’s conscious level  awaken patient as much as possible
(NEVER feed semi/un-conscious patient orally)
◦ Provide opportunity for toileting before meals
◦ Use appropriate feeding tools (e.g. use small spoons if required)
◦ General precautions when assisting patients with meal
◦ Sit up (to 90o if possible) patient during feeding if no contraindication
◦ Prop up (to at least 60o) patient for at least 30 minutes after feeding 
to prevent vomiting & aspiration
◦ Maintain neutral head and chin down posture during feeding
◦ AVOID patient tilting head backwards when feeding
◦ General precautions when assisting patients with meal
◦ Maintain slow rate and small amount per mouthful  don’t rush the
patient to eat
◦ Give sufficient time to patient for chewing and swallowing  give next
spoonful of food only after the first spoonful is swallowed
◦ Watch out for coughing, choking, throat clearing, change of breathing
patterns during or immediately after feeding
◦ STOP feeding patient immediately if patient chokes or vomits during
feeding
◦ Special precautions when assisting dysphagic patients with meal
◦ Cautions with fluids intake  make sure to thicken fluid according to
prescribed formulae if required
◦ Cautions in swallowing fruits, biscuits, bread or home make food items
 make sure they are of similar texture/consistency as recommended
◦ Cautions in using straw for drinking  use small teaspoon instead if
necessary
◦ Perform oral care before and after meal
◦ Follow the feeding instructions prescribed by speech therapist
Client education for healthy nutrition
◦ Instruct the clients about the content of a healthy diet based on

the food guide pyramid
◦ Be more specific
◦ For example, a 65-year-old female of average height and weight who
performs less than 30 minutes of exercise per day requires 1600 Kcal
consisting of the following:
Grains & cereals 3-4 bowls

Vegetables 6-8 taels
Fruits 2-3 portions
Milk, yogurt, and cheese 1-2 glasses
Meat and beans 4-5 taels
◦ Encourage clients, particularly older clients, to reduce dietary fat

◦ Choose a cooking method that uses a minimum amount of oil, such as
steaming, grilling, baking, broiling, or microwaving, rather than frying
◦ Reducing dietary fat

◦ Substitute popcorn or pretzels or other healthy snacks for such snacks
as potato chips, cheese puffs and corn chips

◦ Read food labels  some crackers are high in fat but others are not

◦ Limit desserts high in fat, such as candy, ice cream, cake, and cookies
◦ Use skim or reduced-fat milk instead of whole milk, for drinking as well
as in recipes
◦ Use less butter or margarine on breads
◦ Use less dressing, or use low-fat dressings, on salads

◦ Eat less meat; eat more fish
◦ Eat plant sources of protein
◦ Use nuts as a source of
protein, but since they are
high in fat, use to replace
meat rather than in addition
◦ Remove fat from meat and
skin from chicken before
cooking
◦ Instruct strict vegetarians about proper protein complementation

and additional vitamin (e.g. vit. B12) and mineral (e.g. Ca, Zn, &
Fe) supplementation  vegetarian cook book
◦ Combination of plant proteins that provide complete proteins
Grains Legumes Nuts and seeds
Brown rice Black beans Almonds
Barley Kidney beans Brazil nuts
Corn meal Black-eyed peas Cashews
Rye Soybeans Walnuts
Whole wheat Tofu Sesame seeds
Grains + legumes = complete protein

Legumes + nuts/seeds = complete protein
Grains / legumes / nuts/seeds + milk/milk products (e.g. cheese) =
compete proteins
Examples Rice + black-eyed peas

Cereal with milk
Macaroni with cheese
◦ Discuss importance of
properly fitted dentures and
dental care
◦ Discuss safe food preparation
and preservation techniques
as appropriate
◦ Dietary alterations
◦ Explain the purpose of the diet (e.g. DM diet)
◦ Discuss allowed and excluded foods
◦ Explain the importance of reading food labels when selecting
packaged foods
◦ Reinforce information provided by the dietitian as appropriate
◦ Discuss herbs and spices as alternatives to salt and substitutes for sugar
◦ Include family or significant others in discussion
◦ For clients who are overweight

◦ Discuss physiological, psychological, and lifestyle factors that
predispose to weight gain
◦ Provide information about desired weight range and recommended
calorie intake
◦ Discuss principles of a well-balanced diet and high- and low-calorie
foods
◦ Encourage intake of low-calorie, low salt, low sugar and high dietary
fiber diet
◦ Discuss ways to adapt to eating practices by using smaller plates/bowl,
taking smaller servings, chewing each bite a specified number of times
or putting chopsticks down between bites
◦ Discuss ways to control the desire to eat by taking a walk, drinking a
glass of water, or doing slow deep-breathing exercise

◦ Discuss the importance of exercise and help the client plan an exercise
program.
◦ For clients who are

overweight
◦ Provide information about
available community
resources (e.g. weight-loss
group, dietary counseling,
exercise programs, self-help
groups)

◦ For clients who are underweight

◦ Discuss factors contributing to inadequate nutrition and weight
◦ Discuss recommended calorie intake and desired weight range
◦ Provide information about the content of a balanced diet
◦ Discuss ways to manage, minimize, or alter the factors contributing to
malnourishment
◦ For clients who are

underweight
◦ Provide information about
ways to increase calorie
intake, e.g. high-protein or
high-calorie foods and
supplements.
◦ If appropriate, discuss ways to
purchase low-cost nutritious
foods.
◦ For clients who are underweight

◦ Provide information about community agencies that can assist in
providing food (e.g. Meals-on-Wheels).
◦ Preventing foodborne illness

◦ Reinforce hygienic handling of food and dishes:
◦ Wash hands before preparing foods.
◦ Wash hands and all dishes, utensils, and cutting boards with soap after
contact with raw meats.
◦ Defrost frozen foods in the refrigerator.
◦ Cook meat, poultry, and eggs thoroughly.
◦ Refrigerate leftovers promptly and keep < 3 days.
◦ Wash or peel raw fruits and vegetables.

◦ DO NOT use foods from containers that have been damaged/have opened
seals.
◦ Follow the rules “keep hot foods hot and cold foods cold” and “when in
doubt, throw it out.”
◦ Store raw and cooked food separately  cooked food should be placed in
the upper part of a refrigerator to prevent contamination by dripping of raw
food.

Client education for healthy
nutrition
◦ Recommend the client
consider a preventive
vaccination of hepatitis A
◦ Instruct clients to seek medical
attention for prolonged
vomiting, fever, abdominal
pain, or severe diarrhea
following a meal
Enteral nutrition
◦ Enteral nutrition  feeding through the GI tract
◦ Indications of enteral nutrition:

◦ When patient cannot ingest foods (e.g. nasopharyngeal carcinoma
(NPC) and dysphagia patient)
◦ The upper GI tract is impaired (e.g. Ca tongue patient)  the transport
of food to the small intestine is interrupted
◦ To establish a means for suctioning stomach contents to prevent gastric
distention, nausea, and vomiting
◦ To remove stomach contents for laboratory analysis
◦ To lavage (wash) the stomach in case of poisoning or overdose of
medications
Enteral nutrition
◦ Types of enteral nutrition
◦ Nasogastric (NG/Ryle’s) tube
◦ Gastrostomy & jejunostomy
Enteral nutrition - nasogastric
tube
◦ Nasogastric tube
◦ Inserted through one of the nasal nostrils  down the nasopharynx 
esophagus  stomach
tube
◦ Types of nasogastric tube
◦ Single lumen (Levin) tube
◦ Double lumen (Salem) tube
◦ Small-bore feeding tubes
tube
◦ Single lumen (Levin) tube
◦ Large lumen  feeding and
suction of gastric contents 
with different size (Fr)
◦ Rubber / plastic
◦ Change every 1 week
◦ Poorly visible on X-ray
◦ Silicone
◦ Relatively expensive
◦ Change every 4 weeks
tube
◦ Double lumen (Salem) tube
◦ Large lumen  feeding and
suction of gastric contents
◦ Blue pigtail (air vent)
◦ Visible on X-ray
◦ Less common in HK
tube
◦ Small-bore feeding tubes (Entriflex)
◦ Polyurethane  softer, flexible & less irritating
◦ Change every 3 months
◦ Small lumen  relatively long term feeding
◦ Visible on CXR
◦ Inserted by MO in HK
tube
◦ Nursing management of the client receiving enteral nutrition
◦ Inserting a nasogastric tube
◦ Administering a tube feeding
◦ Prevent aspiration
tube
◦ Inserting a nasogastric (NG) tube
◦ Assessment
◦ Check for history of nasal surgery or deviated septum
◦ Assess injury and patency of nares by a torch
◦ Assess mental status or ability to participate in the procedure
tube
◦ Inserting a nasogastric tube ◦ Basin/kidney dish
◦ Planning ◦ pH test strip

◦ Stethoscope
◦ Before inserting a nasogastric
tube, determine the size and ◦ Torch
type of tube to be inserted ◦ Tongue depressor
◦ Equipment ◦ Disposable pad/towel
◦ Nasal gastric tube (Fr) ◦ Clamp (e.g. Spigot)
◦ Nonallergenic adhesive ◦ PPE, if required
tape (e.g. Micropore)
◦ Commercial securement
◦ Clean gloves device, if available
◦ Water-soluble lubricant ◦ Suction apparatus, if
◦ Facial tissue available
◦ 50-ml catheter tip syringe
tube
◦ Implementation
◦ Perform hand hygiene
◦ Introduce self and verify the client’s identity
◦ Position: assist the client to a high-Fowler’s position (90o) if his/her health
condition permits
◦ Provide privacy
◦ Explain procedure
◦ Place a towel or disposable pad across the chest
tube
◦ Implementation (cont’d)
◦ Assess the client’s nares with torch and clean gloves  Select the nostril that
has the greater airflow or alternate the nostril if change a new NG tube
◦ Prepare the tube and equipment
◦ Determine how far to insert the tube (measure nose  earlobe  xiphoid
process)
◦ Lubricant the tube by water-soluble lubricant for ~10cm
tube
◦ Insert the tube  with its natural curve downward, into the selected nostril  If
the tube meets resistance, withdraw it, re-lubricate it, and insert it in the other
nostril
◦ Once the tube reaches the oropharynx (throat), the client will feel the tube in
the throat and may gag and retch  ask the client to tilt the head forward,
and encourage the client to swallow
tube
◦ Ascertain correct placement of tube by aspirate stomach content and check
pH, and whooshing test
◦ Secure the tube by taping it to the bridge of the client’s nose
◦ Clamp the end of the tubing
◦ Remove and discard gloves
◦ Document relevant information
tube
tube
tube
◦ Evaluation
◦ Conduct appropriate follow-up, such as degree of client comfort, client
tolerance of the nasogastric tube, correct placement of nasogastric tube in
stomach
tube
◦ Testing/confirming feeding tube placement
◦ Time
◦ After the nasogastric tube inserted
◦ Before every feeding
◦ Methods
1. Chest X-ray
2. Aspirate GI secretion
3. Confirm length of tube insertion with the insertion mark
4. Whooshing test
tube
1. Chest x-ray
◦ Most accurate
◦ Expensive and inconvenient
◦ Radiation
tube
tube
2. Aspirate GI secretion (golden rule)
◦ Gastric fluid  grassy-green or off-white color fluid
◦ Testing pH level  1 – 4 (according hospital guideline)
tube
3. Confirm length of tube insertion with the insertion mark
tube
4. Whooshing test
◦ Supplementary test if no gastric fluid aspirated
◦ Using a stethoscope to listen over the epigastric area for the whooshing
sound while a syringe instills a 10ml air bolus in to the patient’s stomach.
tube
◦ Assessment
◦ Any allergies to the food in the feeding?
◦ If the client is lactose intolerant, check the tube feeding formula  notify the
doctor/dietitian if any incompatibilities exist
◦ Any problems that suggest lack of tolerance previous feedings (e.g. delayed
gastric emptying, abdominal distention, diarrhea, cramping, or constipation
from I & O chart)
◦ The type, amount, and frequency of feedings  e.g.
Ensure 250ml X 4/Day and H2O 50ml X 4/Day
tube
◦ Planning (equipment)
◦ Correct type and amount of feeding solution
◦ 50-ml catheter-tip syringe
◦ Basin/kidney dish
◦ Clean gloves
◦ pH test strip
◦ Water
◦ Stethoscope
◦ Calibrated plastic feeding bag with tubing
◦ Medication, if available
◦ Feeding pump, if needed
◦ Measuring container, if needed
tube
◦ Implementation
◦ Introduce self and verify the client’s identity
◦ Position: assist the client to a Fowler’s position (at least 30o) in bed or sitting
position in a chair. If a sitting position is contraindicated, a slightly elevated
right side-lying position is acceptable
◦ Explain procedure
◦ Apply clean gloves
tube
◦ Assess tube placement by aspirate stomach content and check pH, and
whooshing test
◦ Assess residual feeding content to evaluate the absorption of the last feeding
 if 100ml (or > half the last feeding) is withdrawn, check the agency policy
before proceeding  re-instill the gastric contents into the stomach (removal
of the contents could disturb the client’s electrolyte balance)
◦ e.g. clear fluid, digested/undigested milk, coffee ground fluid
tube
◦ Check the expiry date of the
formula
◦ Use feeding bag/syringe to
administer the feeding at a
rate of 5-10ml/minute
◦ Hang the labeled bag from an
infusion pole about 30 cm (12
in.)
tube
◦ Flush the tube with 50 – 100ml of water after feeding according to prescription
◦ Clamp the feeding tube
◦ Dispose of equipment appropriately
◦ Document all relevant information (I & O chart and patient record)
◦ Continuous monitoring for client condition
tube
tube
◦ Evaluation
◦ Tolerance of feeding (e.g. nausea, cramping)
◦ Bowel sounds
◦ Regurgitation and feelings of fullness after feeding
◦ Urine output
◦ Weight gain/loss
tube
◦ Prevent aspiration
◦ Aspiration pneumonia occurs when regurgitated stomach contents or
enteral feedings
◦ Proper administration and delivery techniques of tube feeding (e.g.
correct feeding position and speed)
◦ Monitor gastric residue content before feeding to prevent overfeeding
and aspiration
◦ Maintain semi-fowler position for at least 30 minutes after feeding
Enteral nutrition – enteral
feeding
◦ Prescribe type and
frequency of feedings by
doctor or dietitian
◦ Types of food
◦ Water
◦ Milk formula
◦ Rice water
◦ Liquid feeding mixtures
◦ Other supplements (e.g. protein)
◦ Frequency of feeding
◦ Intermittently
◦ continuously
Enteral nutrition –
enteral feeding
◦ Intermittently
◦ Several times per day (~4 – 6 times)
 e.g.
300ml Ensure x4/day
50ml H2O x4/day
◦ The bag and tubing should be

replaced every 24 hours
Enteral nutrition – enteral
feeding
◦ Continuously
◦ Administered over 24-hour
period using an enteral feeding
pump (milk pump)
◦ ~60ml – 80ml / hour
◦ For feeding into small intestine
◦ Clamp the tubing at least every
4 - 6 hours  aspirate and
measure the gastric contents 
flush the tubing with 30 to 50 mL
of water  to determine
adequate absorption and
verifies correct placement of
the tube
◦ May consider to withhold the
feeding if > 75 - 100 mL of
feeding is aspirated
Enteral nutrition – gastrostomy
& jejunostomy
◦ Gastrostomy & jejunostomy
◦ Feeding tubes placed surgically through abdominal wall into stomach
(gastrostomy) or jejunum (jejunostomy)
◦ Indications:
◦ Long-term non-oral nutritional support (> 6 - 8 mouths), e.g. nasopharyngeal
carcinoma (NPC) patient
& jejunostomy
◦ Using endoscope to visualize
the inside of the stomach 
making a puncture through
the skin & subcutaneous
tissues of the abdomen into
the stomach
◦ Percutaneous endoscopic
gastrostomy (PEG)
◦ Percutaneous endoscopic
jejunostomy (PEJ)
& jejunostomy
◦ The surgical opening is
sutured tightly around the
tube or catheter to prevent
leakage
◦ Care of this opening before it
heals requires surgical asepsis
 daily wound dressing
& jejunostomy
◦ Testing and Feeding via
PEG/PEJ
◦ Verifying tube placement
before each intermittent
feeding and at regular
intervals for continuous
feeding
◦ Confirm length of tube insertion
◦ Aspirate GI secretions
◦ Measure the pH of aspirated
fluid
◦ Measure the residue content in
the stomach
Collection of vomitus & gastric
aspirate
◦ NG tube may be used for decompression for post-operative
patient  it is connected to suction or a collection bag
◦ Nurse needs to record the amount, color, and type of any drainage
every 4 - 8 hours
◦ Aspiration of gastric fluid may be needed according to doctor
prescription (Q1H – Q4H)
◦ Record in the Intake & Output (I & O) chart
Parenteral nutrition
◦ Total parenteral nutrition (TPN) – intravenous infusion of nutrients
including dextrose, water, fat, proteins, electrolytes, vitamins and
trace elements
◦ Indications:
◦ Severe malnutrition
◦ Severe burns
◦ GI disease disorders
◦ Metastatic cancers
◦ Major surgeries where nothing taken by mouth for > 5 days
Parenteral nutrition - TPN
◦ Administration method
◦ 24 hours continuous infusion by infusion pump
◦ Site
◦ Central veins  Subclavian vein
◦ Peripheral veins (rare)
Parenteral nutrition - TPN
◦ Special considerations of TPN
◦ Infection control
◦ Use aseptic technique to handle the TPN and infusion site  e.g. changing
solutions, tubing, & dressings
◦ Frequent monitoring for local infection
◦ Electrolyte imbalance
◦ Rich in fluid, electrolytes, & glucose
◦ Frequent evaluation the patient’s serum electrolyte composition
◦ Frequent modification of TPN mixture
EVALUATION
Nursing management
Evaluation
◦ To evaluate the goals established in the planning phase
◦ Was the cause of the problem correctly identified?
◦ Was the family included in the teaching plan? Are family members
supportive?
◦ Is the client experiencing symptoms that cause loss of appetite (e.g.
pain, nausea, fatigue)?
◦ Were the outcomes unrealistic for this person?
◦ Were the client’s food preferences considered?
◦ Is anything interfering with digestion or absorption of nutrients (e.g.
diarrhea)?
References
Berman, A., & Snyder, S. (2016). Kozier & Erb’s fundamentals of
nursing: Concepts, process, and practice (10th ed.). Upper
Saddle River, New Jersey: Pearson Education.
Grodner, M., Roth, S. L., & Walkingshaw, B. C. (2012). Nutritional

foundations and clinical applications : a nursing approach. St.
Louis, Mo.: Mosby/Elsevier.
Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012).

Dysphagia in the elderly: management and
nutritionalconsiderations. Clinical Interventions in Aging, 7,
287–298.
Wilkinson, J. M. (2016). Fundamentals of nursing (3rd ed.).

Philadelphia: F. A. Davis Co.
Next lab
◦ Week 6 lab I ◦ Week 7 lab II (skill test)
◦ Assessment for swallowing ◦ Nasogastric tube insertion and
difficulties removal
◦ Nutritional screening ◦ Administering enteral feeding
◦ Food preparation ◦ Collection of vomit and
◦ Oral feeding technique gastric aspirate
◦ Record of intake and output ◦ Watch video before lab
chart ◦ Print out the skill test
◦ Declaration form and self assessment
medical surveillance form
Critical thinking checkpoint
Discuss nursing interventions to prevent a patient from aspiration
during oral feeding / nasogastric tube feeding.
Online exercise within 2 weeks

Lecture 4 5 - Fluid and Nutrition III IV

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Lecture 4 5 - Fluid and Nutrition III IV

Uploaded by

Copyright:

Available Formats

FOUNDATION OF NURSING

1 Patients who have nausea

Loss of appetite; diminished sense of smell

3 Nil per oral (NPO)

Patients with impaired swallowing, &

◦ 1. Patients who have nausea

◦ 1. Patients who have nausea (con’t)

2. Loss of appetite; diminished sense of smell & taste  causes:

2. Loss of appetite; diminished sense of smell & taste

2. Loss of appetite; diminished sense of smell & taste

2. Loss of appetite; diminished sense of smell & taste

3. Nil per oral (NPO)

4. Patients with impaired swallowing, digestion or elimination

4. Patients with impaired swallowing, digestion or elimination

4. Patients with impaired swallowing, digestion or elimination

4. Patients with impaired swallowing, digestion or elimination

4. Patients with impaired swallowing, digestion or elimination

4. Patients with impaired swallowing, digestion or elimination

4. Patients with impaired

4. Patients with impaired swallowing, digestion or elimination

◦ Regular diet (正餐)

◦ Clear fluid diet (清流質餐)

◦ Liquid diet (流質餐)

◦ Soft diet (軟餐)

◦ Diet as tolerated (DAT)

◦ Modified diet for diseases – calorie restricted diet

◦ Modified diet for diseases –

◦ Modified diet for diseases – low purine diet (低普林餐)

◦ Modified diet for diseases – low or high potassium diet (低/高鉀餐)

◦ Modified diet for diseases –

◦ Modified diet for dysphagic

◦ Modified diet for religious

◦ Help the patient feed themselves as much as possible

◦ Instruct the clients about the content of a healthy diet based on

Grains & cereals 3-4 bowls

◦ Encourage clients, particularly older clients, to reduce dietary fat

◦ Reducing dietary fat

◦ Reducing dietary fat

◦ Reducing dietary fat

◦ Reducing dietary fat

◦ Instruct strict vegetarians about proper protein complementation

Grains + legumes = complete protein

Examples Rice + black-eyed peas

◦ For clients who are overweight

◦ For clients who are overweight

◦ For clients who are

◦ For clients who are overweight

◦ For clients who are underweight

◦ For clients who are

◦ For clients who are underweight

◦ Preventing foodborne illness

◦ Preventing foodborne illness

◦ Preventing foodborne illness

◦ Indications of enteral nutrition:

◦ Planning ◦ pH test strip

◦ The bag and tubing should be

Grodner, M., Roth, S. L., & Walkingshaw, B. C. (2012). Nutritional

Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012).

Wilkinson, J. M. (2016). Fundamentals of nursing (3rd ed.).

Online exercise within 2 weeks

You might also like