1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 40: Patient Management: Gastrointestinal System

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Introduction Foods consumed support metabolism. Two types of metabolism: –Anabolism: build up and repair –Catabolism: break down and create energy Glucose is the primary energy fuel –Not readily storable by most organs –Must be extracted from blood –Excess is stored as glycogen or triglycerides –Glucose can be changed to fatty acids, but the reverse cannot be done. Fatty acids can be used as energy fuel, but they produce ketones.

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Ketone Use Glucose is primary energy fuel During starvation, the body can use fatty acids as fuel The end product of fatty acid use is ketones Excess ketones wind up in the blood if they aren’t used This is called ketoacidosis

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of Pancreas Glycogenolysis is glycogen breakdown –Medullary control –Role of glucagon and cortisol Gluconeogenesis is glucose production from proteins Insulin is used to transport glucose from the blood into the body cells and tissues –Use of glucose with insulin prevents fatty acid use –Used for protein building

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Malnutrition 15% to 20% of hospitalized patients are malnourished; reasons: –NPO –Hypermetabolic –Increased protein and energy demands Malnutrition leads to immunosuppression and organ dysfunction Three types –Marasmus –Kwashiorkor –Protein-calorie malnutrition

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would be consistent with malnutrition? A. Thin, shiny skin B. Red, beefy, easily bleeding wounds C. Hair loss D. High serum albumin level

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Hair loss Rationale: Hair cells grow rapidly; patients with malnutrition will lose their hair when the nurse combs it, or the nurse may find hair on the bed linen. Thin shiny skin is consistent with decreased blood flow but isn’t consistent with malnutrition. Red, beefy, easily bleeding wounds are those that have re-epithelization. A low serum albumin level is consistent with malnutrition as protein is needed to make albumin.

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Enteral Nutrition Gut needs to have something in it Bacteria translocate into the bloodstream without food The best way to receive food is by mouth Other ways are needed when eating is contraindicated Can give feedings by delivery into the stomach or small bowel

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nasogastric, Nasoduodenal, and Nasojejunal Tubes NASOGASTRIC Nose to stomach NASODUODENAL Nose to duodenum NASOJEJUNAL Nose to jejunum Short-term use due to aspiration risk and nasal erosion Longer-term use as tube lies beyond the pyloric sphincter Longer-term use as even less risk for aspiration than with nasogastric/nasoduo denal tubes Relative ease of insertion Harder to insertHardest to insert as must migrate to jejunum

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A nurse will be inserting a nasojejunal tube to start tube feedings on a patient with pancreatitis. When the nurse auscultates the abdomen, bowel sounds are absent. The nurse decides to hold the tube feeding because this is a risk for aspiration. Should the nurse institute tube feedings? A. Yes B. No

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Yes Rationale: Bowel sounds indicate the motility, not absorptive ability, of the gut. The nurse can institute tube feedings even if bowel sounds are absent. Also, the small bowel is less prone to an ileus, so it is OK to feed this patient.

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Placement and Confirmation of Enteral Tubes Placement –Measurement –Lubrication –Swallowing to help place –Rotate the tube –Use of metoclopramide (Reglan) –Weighted tubes Confirmation of placement –Auscultation –Fluid aspiration –Measuring pH –Radiological confirmation

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is a proton-pump inhibitor? A. Famotidine (Pepcid) B. Sucralfate (Carafate) C. Pantoprazole (Protonix) D. Metoclopramide (Reglan)

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Pantoprazole (Protonix) Rationale: Pantoprazole (Protonix) is the only proton-pump inhibitor listed. Although all of the other medications are useful GI medications, they are not PPIs. Famotidine (Pepcid) is a histamine-2 receptor antagonist, sucralfate (Carafate) is a slurry that provides a protective covering in the stomach, and metochlopramide (Reglan) is a GI motility stimulator useful in decreasing diarrhea with tube feedings.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Gastric Tubes 1.Low-profile gastrostomy (LPGD) 2.Jejunostomy tube 3.Percutaneous endoscopic gastrostomy (PEG) 4.Percutaneous endoscopic gastrostomy with jejunal extender (PEG/J)

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Tube Sites

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Care of Gastric Tubes Securing tubes Document the external length –Assess skin for breakdown Prevent maceration Good hygiene – soap and water cleansing “Buried bumper syndrome”

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Feedings All contain carbohydrates, fats, and proteins Types –Polymeric solutions –Peptide –Modular –Immunonutrition-containing diets

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Frequency of Feedings BOLUS By syringe 5 or 6 times/day CONTINUOUS By feeding pump Continuous CYCLIC During the night (8 to 12 hrs) Requires a feeding pump ADVANTAGE More like eating Increased patient mobility ADVANTAGE Allows more absorption time Less risk of stress ulcers Fewer metabolic problems ADVANTAGE Shorter time High volume and density at night; greater patient mobility DISADVANTAGE Aspiration a problem Increased residuals Cramping, nausea, bloating, and diarrhea DISADVANTAGE “Dumping syndrome” Mechanical device with power source DISADVANTAGE Increased residuals

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Feedings GASTROINTESTINAL –High residuals –Nausea, vomiting, bloating –Diarrhea (most common) –Constipation METABOLIC –Preventing acute renal failure –Preventing overhydration –Hyperglycemia

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications (cont.) INFECTIONS –Aspiration, which is potentially fatal –Occurs with endotracheal intubation about 50% to 75% –Treatments Keep HOB elevated Discontinue 30 minutes before lying flat Aspirate for residuals and trend

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In determining whether a patient has aspirated, blue dye instillations or additions are no longer acceptable practice and can cause more harm to the patient. A. True B. False

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. True Rationale: Using blue dye is no longer an acceptable practice in determining aspiration. Blue dye can cause toxicity, invasion of bacteria, and diarrhea.

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Parenteral Nutrition Delivery of food into the vein instead of the stomach Only short term until food can be instituted, or can be done in combination with enteral/oral nutrition –Will not stop translocation of bacteria Types –PPN (peripheral parenteral nutrition) –TPN (total parenteral nutrition; hyperalimentation)

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Sites for PPN/TPN Delivery

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Differences Between TPN and PPN PPN –Large peripheral vein (basalic vein) –Lower osmolality (<800mOsm/L) –Short term for prevention of malnutrition TPN –Central venous access (superior vena cava or internal jugular) –Higher osmolality –Longer term

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Constituents of Parenteral Therapy Carbohydrates Lipids Amino acids Micronutrients Medications

28. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Parenteral Nutrition GI –Hepatic dysfunction –Cholestasis –Cholelithiasis –Gastric atrophy MECHANICAL –Usually due to central line insertion –Catheter occlusion –Venous thrombosis –Venous air embolism

29. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Parenteral Nutrition (cont.) METABOLIC –Hypokalemia –Hyperglycemia Sliding scale coverage –Hypoglycemia Substitution of D10W (temporary) –Refeeding syndrome INFECTIOUS –High glucose is excellent environment for bacterial growth –Change bag and tubing per protocols –Check insertion site and change dressings –Antibiotics and catheter tip culture if infection is suspected