NCLEX-RN: Nutritional Management

Nutritional Management: Administering Therapeutic Diets

Focus topic: Nutritional Management

Nutritional Management: Restricting Dietary Carbohydrates

Focus topic: Nutritional Management

 

A. Hypoglycemia occurs when most of the glucose moves from the blood into the cells and results in abnormally low blood glucose levels (< 70 mg/dL).

  • Foods prescribed are high protein, moderate-complex carbohydrates in five or six meals/day.
  • Foods limited are simple carbohydrates—for example, sugar, syrup, candy. Complex carbohydrates or starches have higher nutritional values and more fiber.

B. Diabetic guidelines.

  • Nutrition is the cornerstone of disease management.
    a. Normal weight must be maintained and may dramatically reduce symptoms.
    b. Diet together with insulin supplement or oral medication and exercise complete the regimen.
  • Goal of dietary therapy is to have a well-balanced diet and to count carbohydrates (CHO) because CHO raises blood sugar.
    a. Diabetics do not have to give up their favorite foods; they must learn the amounts that are allowed and substitutions permitted.
    ✦b. General guidelines for nutrient balance are:
    Carbohydrate 50–60% (40% from complex CHOs)
    Fat 20–30%
    Saturated fat 10%
    Cholesterol Limit to 300 mg or less
    Protein 10–20% Consume 20–35 grams of fiber daily (including soluble and insoluble)
    c. Dietary ratio: 5:2:1 carbohydrate to fat to protein (according to the American Dietetic Association).

C. Carbohydrate counting is a nutritional tool used to maintain blood glucose levels.

  • Count grams of carbohydrates (type 1 diabetics require more accurate monitoring).
  • Measure servings or choices (more often used with type 2 diabetics). One carbohydrate serving = 15 g carbohydrate with vegetables is counted as one-third serving of carbohydrate.
  • Use the glycemic index, which describes how much the blood glucose level rises with a specific food when compared with an equivalent amount of glucose. Foods with a higher glycemic index enter bloodstream rapidly, causing glucose to spike.
    a. Particular foods (most sugars and items made with white flour) have a higher glycemic index than others.
    b. By combining certain foods, the client may lower the glycemic index and do better at stabilizing blood glucose levels.
    c. Combining a starch with protein or fat will lower the glycemic index.
    d. Eating raw and whole foods and fruit rather than juices will lower glycemic index.
    e. Keeping a chart and building individual glycemic indices by monitoring blood glucose levels after food consumption will improve stabilizing blood glucose levels.
  • The client may choose any method to monitor carbohydrate consumption, but monitoring is essential if blood sugar levels are to remain within normal limits.

D. Level of activity must be assessed to determine energy requirements.

  • Increased activity uses more carbohydrates.
  • Most adults require 30 cal/kg of ideal body weight.Nutritional Management The Glycemic Index of Common Foods

Nutritional Management

Nutritional Management: Restricting Dietary Protein

Focus topic: Nutritional Management

A. A restricted-protein diet is utilized for renal impairment because protein is processed through the kidneys.

  • End products (nitrogenous waste) of protein metabolism are controlled by limiting protein intake.
  • Protein processing uses up calcium reserves.
  • Conditions utilizing restricted protein diets.
    a. Pyelonephritis.
    b. Glomerulonephritis, if oliguria is present.
    c. Kidney insufficiency.
    d. Dialysis management.
    e. Encephalopathy due to liver failure.

B. A PKU diet is an amino acid metabolism abnormality diet utilized for phenylketonuria (PKU), galactosemia, and lactose intolerance.

  • Reduce and/or eliminate the offending enzyme in the food intake of protein and utilize substitute nutrient foods.
  • Avoid milk and milk products as they constitute the main source of enzymes for the three diseases.
  • Employ substitutes to meet daily allowances.

Nutritional Management: Foods High in Protein

Focus topic: Nutritional Management

Nutritional Management

Nutritional Management: Foods High in Purine

Focus topic: Nutritional Management

Nutritional Management

Nutritional Management: Low-Purine Diet

Focus topic: Nutritional Management

A. Prevents uric acid stones; also utilized for gout clients.
B. Restrict purine, which is the precursor of uric acid.
C. Allow foods such as milk, tea, fruit juices, carbonated beverages, breads, cereals, cheese, eggs, fat, and most vegetables.
D. Restrict foods such as glandular meats, gravies, fowl, fish, and high meat quantities.

Nutritional Management: Restricted Dietary Fat

Focus topic: Nutritional Management

A. A restricted-cholesterol diet decreases cardiovascular disease risk and diabetes mellitus.

  • Blood cholesterol level is reduced and/or maintained at a normal level by restricting foods high in cholesterol.
  • Lipid level goals—cholesterol: 160–200 mg/ dL; LDL < 100 mg/dL; HDL > 45 for males and > 55 for females; triglycerides < 150.
    a. Total cholesterol.
    < 200 desirable
    > 240 high
    b. LDL (bad cholesterol).
    < 100 optimal
    160–189 high
    > 190
    c. HDL (good cholesterol).
    < 40 low
    > 60 high
    d. Triglycerides.
    < 150 normal
    200–499 high
  • Restrict total fat to 30% of calories; restrict saturated fat to 10% (or less) of calories.
  • The average person should consume 250–300 mg of cholesterol per day. (One egg has 275 mg of cholesterol; one 3-ounce serving of hamburger has 50 mg of cholesterol.)
  • Substitute trans fats and saturated fat with monounsaturated fats (found in plant products); increase essential fatty acids.
  • Decrease high-cholesterol foods found in animal products—for example, egg yolks, shellfish, organs and red meat, and pork.
  • Encourage low-cholesterol foods, such as vegetable oils, raw or cooked vegetables, fruits, lean meats, and fowl.

Nutritional Management: Foods High in Cholesterol

Focus topic: Nutritional Management

Nutritional Management

B. A modified-fat diet is utilized according to individual tolerance in specific diseases and conditions and for those wishing to lose weight.

  • Attempt to lower fat content in diet to reduce irritation of diseased organs and to reduce fat content where there is inadequate absorption.
  • Modified-fat diets are appropriate for the following conditions:
    a. Malabsorption syndromes.
    b. Cystic fibrosis.

C. A polyunsaturated-fat diet is utilized primarily for cardiovascular diseases.

  • Reduce intake of saturated fats and increase intake of foods rich in polyunsaturated fats. (Physician usually prescribes caloric level as well as restrictions.)
  • Limit foods originating from animal sources and selected plants, such as peanuts, olives, avocado, coconuts, chocolate, and cashew nuts.
  • Allow foods originating from vegetable sources (except for those named above), butter substitute, corn/soybean/safflower oil, fresh ground peanut butter, and nuts (except cashews).

Nutritional Management: Vitamins

Focus topic: Nutritional Management

A. An increased-vitamin diet is necessary for treatment of specific vitamin deficiencies.

  • Provide a high-vitamin diet for clients with burns, healing wounds, raised temperatures, and infections. Also used for pregnant clients.
  • Evaluate diseases, such as cystic fibrosis and liver disease, that require water-soluble vitamins.

B. Total low-vitamin diets are not generally prescribed, although specific vitamins might be decreased for periods of illness.

Nutritional Management: Minerals

Focus topic: Nutritional Management

A. Sodium restriction.

  • Correct and/or control the retention of sodium and water in the body by limiting sodium intake. May be done by restriction of salt in the diet or in combination with medications.
  • Restrict salt in cooking or at the table. In clients requiring dietary modification in salt intake, any product containing sodium, such as sodium bicarbonate, may be prohibited.
  • The typical diet provides 4–6 g of sodium per day.
  • Sodium dietary restrictions. (See Table 4-10.)
    a. Mild: 2–3 g sodium (no added salt provides 3 g sodium per day).
    b. Moderate: 1500 mg sodium.
  • Conditions utilizing low sodium in their management.
    a. Ménière’s disease.
    b. Edema in congestive heart failure.
    c. Right ventricular failure.
    d. Hypertension.
    e. Cirrhosis with edema.
    f. Portal hypertension.
    g. Uremia.
    h. Dialysis management.
    i. Pregnancy-induced hypertension.

Nutritional Management: Major Food Sources of Vitamins

Focus topic: Nutritional Management

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Nutritional Management: Foods High in Sodium

Focus topic: Nutritional Management

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B. Potassium management.

  • Replace potassium loss from the body with specific foods high in potassium or a potassium supplement. Severe loss is managed with intravenous therapy.
  • Avoid no specific foods unless there is a sodium restriction because some foods high in potassium are also high in sodium.
  • Conditions requiring low potassium.
    a. Glomerulonephritis.
    b. Dialysis management.
  • Conditions requiring increased potassium.
    a. Diabetic acidosis.
    b. Burns, after the first 48 hours.
    c. Vomiting.
    d. Extended high temperature.
    e. Use of diuretic drugs.

C. Enhanced-calcium diet.

  • Used to prevent or correct postmenopausal osteoporosis and prevent and treat hypertension.
  • Increase normal adult intake of 1 g/day to 1.5 g/day.
  • Recommend use of fortified low-fat and nonfat dairy products.
  • Lactose-intolerant clients should use green, leafy vegetables and nonliquid dairy products (cheese, yogurt).

Nutritional Management: Foods High in Potassium*

Focus topic: Nutritional Management

Nutritional Management

D. Iron supplements.

  • Replace a deficit of iron caused by inadequate intake or chronic blood loss. Women especially tend to be low in iron.
  • Suggested iron intake is 18 mg/day.
  • Conditions utilizing high iron in their management.
    a. Peptic ulcer disease.
    b. Diverticulosis.
    c. Ulcerative colitis.
    d. Anemias: nutritional, pernicious.

e. Hemorrhage.
f. Postgastrectomy syndrome.
g. Malabsorption syndrome.
h. Crohn’s disease.
i. Increased for pregnancy and lactation.

Nutritional Management: Foods High in Calcium

Focus topic: Nutritional Management

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Nutritional Management: Foods High in Iron

Focus topic: Nutritional Management

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Nutritional Management: Fiber Control

Focus topic: Nutritional Management

✦ A. A high-fiber (roughage) diet is an important constituent of our diet. The average person eats 20 g of fiber per day; 30–40 g is recommended.

  • High-fiber foods help a person lose weight, keep the heart healthy, and lower the risk of developing colon cancer (examples are bran, cereals, beans, fruits, and vegetables).
  • Foods low in carbohydrates are usually high in residue, and vice versa.

B. There are two types of fiber.

  • Insoluble fibers are found in the cell walls of plants; they do not dissolve in water. They speed up elimination of waste products.
  • Soluble fibers (oat bran) dissolve in water. They decrease cholesterol levels and slow absorption of glucose so blood sugar levels are reduced in diabetes.

C. A low-residue diet (foods high in fiber) is utilized for certain diseases and conditions.

  • Low-residue foods include ground meat, fish, broiled chicken without skin, creamed cheeses, limited fat, warm drinks, refined strained cereals, and white bread.
  • Conditions that require a low-residue diet.
    a. Crohn’s disease.
    b. Postoperative colon and rectal surgery.
    c. Diverticulitis—while inflammatory period lasts.
    d. Diarrhea and enteritis.

Nutritional Management: Bland Food Diets

Focus topic: Nutritional Management

✦A. A bland diet promotes healing of the gastric
mucosa. It eliminates food sources that
are chemically and mechanically irritating.

  • Bland diets are presented in stages with the gradual addition of certain foods.
  • Frequent, small feedings during active stress periods are important.

B. Move from bland to regular diet and establish regular meals and food patterns when condition permits.
C. Bland diets may be appropriate for the following conditions:

  • Duodenal and gastric ulcers.
  • Chronic pancreatitis.
  • Prostate surgery, postoperative.
  • Stomach surgery, postoperative.

Nutritional Management: Preoperative and Postoperative Diets

Focus topic: Nutritional Management

✦A. A high-protein preoperative diet is essential for the maintenance of normal serum protein levels during and following surgery.
B. This diet also restores nitrogen balance if protein depleted for burn victims, the elderly, and severely debilitated clients.

  • Provide adequate carbohydrates to maintain liver glycogen and adequate amino acids to promote wound healing.
  • Provide a 2500-calorie diet that is high in carbohydrates, moderate in protein with high-protein supplements.
  • Instruct client that an elemental diet is low in residue and contains a synthetic mixture of CHO, amino acids, and essential fatty acids with added minerals and vitamins. It is bulk free and easily assimilated and absorbed.

Nutritional Management: Bland Diet Allowances

Focus topic: Nutritional Management

Nutritional Management

Nutritional Management: Postoperative Surgical Diet

Focus topic: Nutritional Management

✦A. Provide 2800 total calories for tissue repair andeven more calories for extensive repair.
B. Fluid intake: 2000–3000 mL/day for uncomplicated surgery and 3000–4000 mL/day for sepsis or renal damage. Seriously ill clients with drainage can require more fluid.

Nutritional Management: Postoperative Diet Progression

Focus topic: Nutritional Management

✦A. Nothing by mouth the day of surgery.
B. A clear-liquid diet is 1000–1500 mL/day and composed of water, tea, broth, Jello, and juices (apple, cranberry) or 7-Up. Avoid juices with pulp.
C. A full-liquid diet lacks many nutrients, so it is used temporarily. It includes clear liquids, milk and milk products, custard, puddings, creamed soups, sherbet, ice cream, and any fruit juice.
D. A surgical soft diet is full liquid and, in addition, pureed vegetables, eggs (not fried), milk, cheese, fish, fowl, tender beef, veal, potatoes, and cooked fruit. Do not include gas-formers.
E. General diet: Take into consideration specific alterations necessary for client’s health status.

Nutritional Management: Mechanical Soft Diet

Focus topic: Nutritional Management

A. A mechanical soft diet is used when clients are edentulous, have poorly fitted dentures, have difficulty chewing, or do not chew food thoroughly.
B. Any food that can be easily broken down can be included in this diet. It allows clients variations in taste that are not allowed on a soft diet (chili beans).

Nutritional Management: Puree Diet

Focus topic: Nutritional Management

A. A puree diet provides food that has been mashed or blended to a smooth consistency.

  • Mainly used for clients with dysphagia or who are unable to chew.
  • Often used with small babies.
  • Some hospitals provide this type of diet for gastrostomy feedings.

B. When assisting clients with this type of diet, talk with them about the meal, describing the different foods; when the texture is all the same, distinguishing between foods is difficult.
C. Do not mix all pureed foods together or feed the client out of one bowl or dish. Try to keep foods separate and feed alternately, with dessert being last.

Nutritional Management: Summary of Dietary Control For Disorders

Focus topic: Nutritional Management

Nutritional Management

Nutritional Management: Providing Nutrients Through Enteral Feeding

Focus topic: Nutritional Management

Assessment
A. Assess overall status.

  • Weight change/loss; temperature.
  • Presence of sepsis; trauma.
  • Mental state.
  • Other medically related nutritional problems (e.g., diabetes, hyperlipidemia, alcoholism).
  • For all of the following procedures, identify client using three methods.

B. Evaluate oral intake.
C. Assess nutritional requirements.
D. Assess status of GI tract.
E. Assess capacity to chew and swallow; assess risk for aspiration.
F. Assess for presence of gag reflex.
G. Evaluate respiratory or thoracic conditions.

H. Check for renal complications.
I. Check for vomiting and/or diarrhea.
J. With high-protein diets, assess for fluid and electrolyte imbalance.

Nutritional Management: Implementation

Focus topic: Nutritional Management

A. Inserting a large-bore nasogastric (NG) tube.
✥ Procedure ✥

  • Check order for tube feeding.
  • Warm feeding to room temperature.
  • Discuss procedure with the client.
  • Demonstrate and display items to be used in order to allay the client’s fear and to gain cooperation.
  • Perform hand hygiene and don gloves.
  • Position the client at 45-degree angle or more.
  • Examine nostrils and select the more patent.
  • Measure from tip of nose to earlobe to xiphoid process of sternum (NEX). If tube is to go below stomach, small flex-tube is used. Mark point on tube with tape.
  • Lubricate first 10 cm of tube with watersoluble lubricant and stylet if used.
  • Insert tube through nostril to back of throat and ask client to swallow. Sips of water may aid in pushing tubing past oropharynx.
  • Instruct client to flex head forward to help
    prevent tube entering client’s airway.
  • Continue advancing tube until taped mark is reached.
  • Tape securely to nose and cheek.
  • Check position of tube.
    ✦a. The most accurate method is to aspirate gastric contents, sometimes difficult with small-bore tubes, and check the pH. If pH is acidic (gastric contents are usually pH 5 or less, greenish to tan or off-white), tube is in the stomach. If NG tube is in respiratory tree, the gastric contents will be pH 6 or more, clear to light yellow.
    ✦b. It is no longer considered safe practice to place proximal end of NG tube in a glass of water and observe for bubbling.
    c. Obtain x-ray to confirm correct placement.
  • Remain with and talk with client until anxiety is decreased and client is comfortable.

Nutritional Management

B. Irrigating a nasogastric (NG) tube.
✥ Procedure ✥

  • Obtain a disposable irrigation set or emesis basin for irrigation solution, a 50-mL syringe, and a normal saline irrigation solution.
  • Perform hand hygiene and don gloves.
  • Place client in semi-Fowler’s position.
  • Disconnect NG tube from suction, if necessary, and check for tube placement.
  • Draw up 20–30 mL normal saline into the irrigating syringe.
  • Gently instill the normal saline into the NG tube. Do not force the solution.
  • Withdraw the irrigation solution and empty into basin.
  • Repeat the procedure twice.
  • Record on I&O sheet the irrigation solution that has not been returned.

✦C. Administering an enteral feeding (TPN).
✥ Procedure ✥

  • Check order from the physician for appropriate formula (calories and/or amount).
  • Check early in shift to ensure adequate formula is available.
  • Warm formula to room temperature—DO NOT use microwave oven.
  • Assemble feeding equipment. If using bag, fill with ordered amount of formula.
  • Explain procedure to the client and assure privacy.
  • Check for presence of bowel sounds.
    a. Now considered to be questionable; instead, assess that client does not have abdominal distention, nausea, or pain.
    b. If client does have flatus or bowel elimination.
  • Place the client on right side in high-Fowler’s position.
  • Aspirate stomach contents to determine amount of residual. If residual volume is greater than 200 mL, further assessment is indicated.
  • Return aspirated contents to stomach to prevent electrolyte imbalance.
  • Pinch the tubing to prevent air from entering stomach.
  • Attach syringe to NG tube.
  • Fill syringe with formula. (If using feeding bag, adjust drip rate to infuse over 30 minutes.)
  • Hold tubing no more than 39 cm above client.
  • Allow formula to infuse slowly (between 20 to 35 minutes) through the tubing.
  • Follow tube feeding with water in amount ordered.
  • Clamp end of the tube.
  • Wash tray and return it to client’s bedside— change syringe daily.
  • Give water between feedings if tube feeding is the sole source of nutrition.

D. Administering continuous tube feedings (Dobhoff, Keofeed tubes).
✥ Procedure ✥

  • Complete steps 1 through 5 of previous skill.
  • Elevate head of bed 30 degrees.
  • Check length of exposed tubing—an increase may indicate tube has dislocated upward.
  • Check patency of existing tube.
  • Irrigate feeding tube with sterile water or saline at least every 8 hours.
  • Administer formula at prescribed infusion rate (usually 60–80 mL/hr). Infusion pumps are used to maintain continuous flow.
  • Avoid keeping formula at room temperature for longer than 4 hours to prevent spoilage and bacterial contamination.
  • urn off flow when placing client supine.

E. Administering gastrostomy feeding.
✥ Procedure ✥

  • Assess gastric contents to determine amount per intermittent feeding. Further assessment is needed if residual is greater than 200 mL.
  • Return aspirated contents to stomach.
  • Feed slowly (flow by gravity) for intermittent feeding (usually 20–35 minutes). Keep at prescribed rate for continuous feeding.
  • Observe gastrostomy tube insertion site for signs of dislodging or infection.
  • Provide site care; wash area with warm water and soap.
  • Apply skin protective barrier. Cover area with sterile dressing.

Gastrostomy feeding—tubing is held straight up from insertion point.

Nutritional Management

PEG for gastrostomy feedings.

Nutritional Management

Total Nutritional Alimentation, Also Called Total Parenteral Nutrition via Central Venous Catheter

✥ Procedure ✥

✦ Assessment

A. Assess nutritional needs of clients unable to ingest calories normally.

Central venous catheter insertion for total nutritional alimentation ( TNA)—right subclavian vein is preferred access to right atrium.

Nutritional Management

B. Identify the caloric intake necessary to promote positive nitrogen balance, tissue repair, and growth; lipids included in formula.
C. Observe for correct additives in each hyperalimentation bag.
D. Check label of solution against physician’s orders.
E. Check rate of infusion on physician’s orders.
F. Assess ability of client to understand instructions during procedure.
G. Confirm position of central venous line following insertion.
H. Observe catheter insertion site for signs of infection, thrombophlebitis, or possible infiltration.
I. Inspect dressing over central line to ensure a dry, noncontaminated dressing.
J. Assess client for pneumothorax.

Implementation
✦A. Teach Valsalva’s maneuver if client does not have a
cardiac disorder. This maneuver prevents air from
entering the catheter during catheter insertion or
tubing changes.

  • Ask client to take a deep breath and bear down.
  • Apply gentle pressure to the abdomen.

B. Review physician’s order for correct hyperalimentation solution additives.

  • TNA bottles come directly from the pharmacy and are numbered sequentially.
  • Each TNA bag label will include client’s name, room number, additives, IV number, start time, date, and stop time.
  • Inspect TNA bag for cracks, turbidity, or precipitates.

C. Assemble IV system with in-line filter and prime IV tubing and filter with solution.
✦D. Position client in head-down position with head turned to opposite direction of catheter insertion site. Place a small roll between client’s shoulders to expose insertion site.
E. Cleanse insertion area with antimicrobial swabs.

F. Perform hand hygiene, don a mask and sterile gloves, and assist physician as needed during catheter insertion.
G. Instruct client in Valsalva’s maneuver when stylet is removed from catheter and when IV tubing is connected to catheter.

  • After tubing is connected, instruct client to breathe normally.
  • Tape area between tubing and catheter hub.

✦H. Turn on IV infusion pump, using normal saline solution at a slow rate of 10 drops/min until x-ray ensures accurate catheter placement. (Flush catheter with saline and heparinize with dilute heparin according to agency policy.)

✦I. Prior to use confirm catheter placement via x-ray and change IV solution to hyperalimentation solution.

  • Store hyperalimentation solution in refrigerator until 30 minutes before use. This prevents growth of organisms, but should be warmed to room temperature prior to use.
  • Change solution every 12 to 24 hours to prevent growth of bacterial organisms.

J. Use IV pump for administration. Time tape the bottle after adjusting flow rate. Be prepared to document on IV hourly infusion record.

K. Observe for complications with TNA.

  • Allergic responses to protein (chills, increased temperature, nausea, headache, urticaria, dyspnea).
  • Air embolism—potentially fatal (respiratory distress, chest pain, dyspnea, hypotension).
  • Catheter-related infection (sepsis). Symptoms of fever, chills, erythema at insertion site.
  • Hyperglycemia—elevated glucose levels.
  • Hypoglycemia—decreased blood glucose levels.

L. Take vital signs every 4 hours.
✦M. Maintain central vein infusion.

  • Apply 4 Ă— 4 sterile gauze pad over IV site and occlude dressing with micropore or plastic tape.
  • Change IV tubing, filter, and infusion pump cassette (if used) every 24 hours.
  • Change extension tubing every 48 hours. Change solution every 12–24 hours (prevents growth of bacteria when using sugar in solution).
  • Maintain IV flow rate at prescribed rate.
    a. If rate is too rapid, hyperosmolar diuresis occurs (excess sugar will be excreted); if severe enough, intractable seizures, coma, and death can occur.
    b. If rate is too slow, little benefit will be derived from the calories and nitrogen.
    c. Do not correct an overload or deficit in flow, as doing so could result in complications for the client. Notify physician if this occurs.

✦N. Check client’s finger stick blood sugar every 6 hours. If necessary, administer regular insulin according to prescribed “sliding scale.”
O. Maintain accurate I&O. Record on special TNA sheet at least every 4 hours.
P. Weigh daily and record on graphic sheet and TNA sheet.

Dressing and Tubing Change
✥ Procedure ✥

✦A. Maintain sterile technique for both procedures.

  • Use sterile gloves, mask, drape, and equipment.
  • Goal is to prevent contamination of site and prevent central line-associated bloodstream infection (CLABSI).

B. Observe insertion site for erythema, drainage, etc., then cleanse with chlorhexidine gluconate – CHG (aka ChloraPrep). Cover with a patch or dressing impregnated with CHG.
C. Change gauze dressings every 48 to 72 hours. Transparent dressing can be changed every 72 to 96 hours.
D. Change tubing every 24 hours.

  • Loosen tubing at catheter hub.
  • Tell client to hold breath and bear down while new tubing is inserted to prevent air from entering catheter causing air embolism.
  • Observe for signs of respiratory distress: air embolism, pneumothorax.
    a. Cyanosis.
    b. Hypotension.
    c. Rapid, weak pulse.
    d. Alterations in heart sounds.
    e. Elevated central venous pressure (CVP).
  • Check vital signs frequently, including temperature.
  • If respiratory distress occurs—suspect air embolism.
    a. Place client in Trendelenburg’s position with client lying on left side.
    b. Inform physician.
    c. Administer oxygen at 6 L/min via nasal prongs.

Hyperalimentation for Children

A. Examine solution.

  • Generally, there is a higher concentration of calcium, phosphorus, magnesium, and vitamins.
  • Usually, a 10% solution of dextrose with 2% amino acids is started—it can be increased to 25% if tolerated.

B. Monitor patency of catheter (usually placed through internal or external jugular or scalp veins). Stopcocks are never used. Monitor constant infusion pump and filter.
✦ C. Obtain fingerstick blood samples. Sugar level will rise, but usually exogenous insulin is not required as the pancreas adapts to high glucose loads.
D. Change the dressing every 96 hours and the tubing every 24 hours using aseptic technique.

  • Stockinette can be used to keep scalp dressing secure.
  • Tight-fitting T-shirt can keep chest site secure.

E. Monitor for accurate rate of infusion.

  • Do not “catch up” if infusion is behind.
  • Positive pressure pumps can be used to maintain infusion rates, particularly when small amounts of solution are being infused.

F. Observe the child when ambulating for accidents such as twisting or kinking the tubing, getting the tubing caught in the crib, or stepping on it.

Nutritional Assessment Parameters

Nutritional Management

Nutritional Management

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