okay yeah expressed appreciation for whoever it is that okay so we’re going to follow up the Tuesday’s nutrition lecture with enteral nutrition today hopefully this won’t be so redundant because I don’t think it kind of lecture on this before but in Terrell nutrition is nutrition that’s delivered through a functioning GI tract bypassing the oral cavity whether it’s a tube that goes through your snout or like a g-tube that’s comes out of your your stomach so it’s for a person that their GI tract cultivates it can it can absorb things it can digest things but they just for whatever reason they can’t have things through their cavity or they can’t get enough food through their opening so indications for this would be somebody who has anorexia I’ve never actually understood it but if someone has severe anorexia and needs to gain weight and it’s that psychological thing where they they literally like cannot get themselves to throw menu in their opening and so if they go into the hospital they’ll employ an NG tube in short term and give them nutrition to slowly have them gain a little bit of weight oral facial faultings so like given that it doesn’t involve the snout or oral arena where you’re frame the tube but perhaps they can’t ruminate or swallow because of the cracking honcho that cancer is a lot of times the tumors will push on your throat or your esophagus and so you can’t get food down but your digestive arrangement still acts neurologic or psychiatric provisions a great deal of people in the hospital that I meet with PEG tubes or G tubings are people with spastic paralysis so just a neurologic you know you’re born with it kind of developmentally disabled condition where it’s unsafe in order to be allowed to or they don’t you know they don’t have the developmental grade to know how to throw nutrient in their mouth safely extended burns and critical illness when you’re just so ill that you’re on hooked up to so many tubings and you’re tranquilize and you’re so out of it that you’re not able to eat so contraindications to enteral feeding so mostly how I said like it’s for someone with a functioning GI tract so basically anything that establishes your GI tract not functioning or doesn’t function at its fullest so a GI obstruction ileus which are kind of nearly the same thing ileus is when the guts aren’t working so there’s not urge peristalsis through so it’s basically a blockage severe diarrhea vomiting or entero cutaneous fistula which is rare but it’s when your bowels like if you have some kind of inflammatory disorder the bowels are creating fistulas abscess like that are connecting to other organs or or your bark or or something it’s mostly a flaw in your speak so I don’t know if you guys can see this very well but it’s an algorithm or perhaps you have it on your newspaper but it’s an algorithm kind of to determine who is going to need an Terrell Nutrition so if someone that needs nutritional assist and “havent been” contraindications so no obstruction ileus peritonitis anything that contraindicate having the tube so we go to in Terrell nutrition long term would be the the gastrostomy or jujin ostomy so that’s an Austin that’s like a stoma coming out of now a gap in your in your abdomen and then short-term needs would be nasogastric need to see a duodenal needs of jejunal are those can also all be oral or Oh gastric or duodenal it’s much more common to see a nasal tubing though I actually never seen one with the oral feeding – but nasal tube going into the stomach as needs a gastric duodenal – june all it precisely depends on how far down in your GI tract the tube goes and then it kind of goes into if your GI function is normal or endangered what kind of formula then would that we put through and then the other side of the algorithm which we’re not going to go over today is mother own parenteral nutrition so somebody without a functioning GI tract that needs nutrition has to go through their veins so these are types of tubings so nasogastric like that I just has spoken about the nasogastric through the nose to the stomach I’ve never seen what “its like” I this is really rare I’m sure I considered a gale I exclusively know how to say it esophagus to me I’ve never seen one of those I think it’s probably pretty rare gastrostomy so simply the whole inserted in your stomach jujin ostomy so these are due on OA or jejunal depending on how far down so the orally or nasally positioned ones when you attend someone with the tube coming out of their snout those are for a short term I signify someone can’t long-term have that that there it’s just it’s not good for your tissues and great scalp breakdown there’s a whole bunch of reasons you don’t want that there long term but short term if it’s expected for less than four weeks then it could be an oral oral or nasal tube and by the way when I talk about like nasogastric tubes have you guys seen beings in the hospital with the suction that’s nasogastric tubes and they’re attached to suction those are like really big those are like I’m 14 to 16 French or something so like that’s different that’s the suctioning the tubes for suction been a great deal bigger than the feeding tubes the feeding tubes are like 8 to 12 French they’re like little like thinner than a pencil and and this really is four things going in versus suctioning out and then if you’re expected to need it for more than four weeks so that’s like someone with cerebral palsy where you know they’re not gonna like come out of that they’re going to need enteral nutrition for the rest of their life mostly it’s going to be either a G tubing or a j2 which that’s the the traditional surgical approach where we are really exactly put you under general anesthesia make a cut in your abdomen and insert it and then the newer like because of technology the newer species is percutaneously positioned and that’s where they introduce a endoscope down here oh I have a picture they’re trying to describe this so they put an endoscope down your esophagus and that creates like the camera and some implements down there and then they can so they kind of come in from both sides and it’s it’s less invasive and all it doesn’t require general anesthesia it’s just like local anesthesia and IV sedation so this is kind of like the newer less less dangerous and like easier recuperation type of insertion okay and then we various kinds of saw in those pictures but the tubes can interrupt and your belly which is nasogastric or in your duodenum or jejunum so and the above reasons for for vanishing furthest down in the stomach is a risk for ideal so you don’t want to be arrange a bunch of formula into someone straight-shooting into someone’s tummy if they have a high risk for intention or regurgitation if they already have like Gerda or some kind of thing that’s going to build them kind of regurgitate things they have that much higher risk of of aspirating the formula so someone with the risk for aspiration is leading they’re going to prefer that it goes all the way down past the pylorus is that what’s called thank you yes so it’s passed the tummy so it’s not going to regurgitate up into into your lungs did you have a question there still is a risk infection yes there still is a risk for infection it’s lower than with traditional surgery but there still is and then the most common tube that is most common tube I see in the hospitals for feeding as a nasal duodenal tube called a dub HOF that’s the brand name so a lot like that’s just what we’d call it we like oh did you flush are aware of off extremely and like if you ever hear that term thrown around that’s a nasal duodenal very and then contraindications for a nasogastric is facial pain like to the nasal area certainly you don’t want to make a tubing down in a traumatic place snout frequent nosebleeds or someone on anticoagulation care so that if they’re really prone to bleeding you don’t want us to try to stick a tube down their nose all the way down their tissues it’s just going to create a risk for bleeding okay so once we have the tube in there’s different kinds of feedings there’s a perpetual infusion that uses a shoot and then a cyclical mixture these are basically the same thing what’s your question well they might be on aspirin as like a general prophylactic said here today that again perhaps or like if they even if they were on coumadin and they needed nutritional patronize I don’t know if they would think about giving them a peg tube or I don’t know I convey if it was going to be long-term they are only settled a peg gym in you know and I’m not sure but I entail I make most to who are we don’t really like place people on coumadin just for a mobility generally we don’t set beings on coumadin until they have a clot so general prophylaxis for first-class like aspirin so and now to be okay they’re just on aspirin that’s fine cumin is kind of like the large-hearted like okay they’re gonna bleed if we do anything so endless in cyclical are like various kinds of the same thing perpetual would be like 24 hours a day we don’t really do that it’s not very practical in a hospice there’s too many stoppages so most people these days are doing cyclical which exactly means it’s most of the day but there’s some downtime so like in our Hospital I think it’s like 3 p. m.To 9 a. m. or something but there’s a there’s a protocol for I know your prescribe decide when you have a patient on feeding your tell will say like start feeding at this time at this pace until this time and that allows for downtime so it’s usually in the morning so you can do your bathing your ADL’s or physical therapy like anything that you know you don’t want someone hooked up to a tube to be doing and then there’s intermittent infusion by gravity we’re like someone would just kind of like have like a little device that they move the liquid in and it only you simply spurt into the tube by seriousnes and that’s more common in the home setting if somebody like with cerebral palsy at home they have a caregiver or their parents or whoever are feeding them can do the time kind of pour the fluid the liquid in and make it kind of drain in for the feeding but um I think they say you want it to be like 20 to 30 minutes and there’s like a clamp on it so like if it’s jostle in too fast you can kind of go in a little a little bit and then intermittent bolus by syringe so same thing so it’s intermittent sporadic and you’re using one of those have you guys seen those big-hearted like 60 ml syringes and so you leant the formula in there and infuse it and that’s also more common in the home setting in the hospital setting is mostly everything is on a spout and most likely going to be the cyclical manner where the government has that downtime okay so it’s cyclical or endless because they’re kind of the same thing so when we start someone on a tube feedings we want to start gradually like just like anything we want to see if someone tolerates something we don’t want to start putting tons of a new formula in someone’s system without letting them get was just about to it but we still use full fortitude formula we don’t like diluted it with irrigate diluting with ocean and this is the risk of bacterial taint so when you have a patient that’s starting a tube feeding your doctor will tell it and say like start at 30 ml’s an hour four times four hours you know if digested enhanced by 30 ml an hour every four hours or whatever there will be like a very precise like formula that your formula utilization that term loosely like or very precise order that will tell you precisely like how to start it when to how often to increase it and by what C and titrated oh I said four so titrate every eight to 12 hours toward the goal charge oh so your prescribe will also say the goal right it’ll say like the goals and targets right is 80 ml as an hour or something and so you’re trying to titrate it toward this goal right and then you’re monitoring the patient frequently because you want to see if they’re tolerating it if they’re not they would have high-pitched gastric residues which I’ll talk about what those are nausea or vomiting but if they’re complain of cramping or any type of abdominal inconvenience after you start or diarrhea so these formulae are very awfully like hyperosmolar and so you threw it into someone’s system and just like it’s has like such hyperosmolarity that like plucked in all the water into your GI tract and then it’s like plucking in too much water you just have diarrhea yeah you just say and then you only get dehydrated so it’s kind of a high risk for that so that’s why “were starting to” very slow so your body can kind of adjust to it and you can stay hydrated okay so this is an example of an occasional feeding like I said these would be most likely to be done at home and you know it’s like the dwelling health giving I don’t know what the requires look like but it would tell you something like to initiate it at a small amount per feeding and then increase it by this sum every feeding until you reach your your goal goal amount and so you typically have like 200 500 ml per feeding and four to six per epoch so like every every four to six hours have a feeding and then administer over twenty to thirty minutes so this can either be like a syringe or like I was talking about I don’t even know what they’re announced but it’s just various kinds of there’s like these receptacles that panels like us are into another wider and they have an open top and you simply pour it in and make it let it flow in and this would be like a gastrostomy or Juden ostomy and then so there’s four types of formulae there’s only one that’s most common in the hospital but I’m gonna go over all four of them so polymeric is some kind of thing that like the caregiver gives up like they’re blending at Whole Foods mostly into a smoothie that they then put down the tube so it’s nutritionally complete so it’s like eating real meat it’s just that someone’s pulverized it so that we are able to gave it through your g2 but your GI tract must be like fully functioning to to suck all those nutrients and then modular is just like us like a complement basically a single macronutrient protein or fatty or whatever the patient needs specific so it’s only meant to supplement so that’s for someone that maybe they are eating but for whatever reason they have a higher requirement of protein or something and they can’t get it through their speak I guess so it’s more like merely a add-on to go to their tube and it’s not end nutrient and then so elemental that’s the most frequent in the hospital if it’s a like a formula that someone’s like fabricated that is nutritionally terminated and it’s predigested to be easier on the GI tract which I entail most people in infirmary who are sick they’re probably not going to have the highest functioning arrangements regardless so it’s a little easier on that and then specialty formulas are like first up like diabetics so I’ve had situate a pattern of that here so GU sir none that would be like one that you will see in the hospital for a diabetic patient who’s on a tubing feeding they come in these little cans it looks like a little like soda can and you only sounds them open and like pour it in the the pocket that the tube feeding is attached to so primals the type you’ll see most often in the hospital and then specialty I’ve actually only determined lucerna I haven’t seen I don’t know what those special ones are for liver failure Holmen area disease or HIV but I guess merely do it there are specialty services yeah I convey only that it’s milkface so cool Emmerich is something that like somebody constitutes that in the home or something like something like I like say I placed some like like milk and like protein gunpowder and like vitamins or whatever and I like mixture all together and I mix it up and then I give it to my child or something and primal is like this manufactured formula where someone’s like chemically decided how much carbohydrates and fast and like and they put in this can and it’s like ready to use okay mmm but they’re both I consider what your point though is that they’re both nutritionally ended but yeah but yeah once creating one’s more like a is a smoothie what about the modular you said that it was not how did they get the other so they would most likely be able to eat a little bit but they’re probably not able to get everything they need and so it’s more it’s like a supplementary everything so I’m not going to go into like all the specific steps have been sorting an NG tube you guys are going to do that in your skills laboratory and they’ll teach you exactly like how to do and how to arrangement the patient’s and material but just like a little like heads up about it so I talked about this already the length is that 8 to 12 French smaller than the one you see that you is used for suction or decompression it has like a navigate cable insert into it so that once you you it toughens it so that once you’re and when you’re inserting it it’s easier to serve but then once you know it’s in the liberty statu you withdraw existing navigate wire it’s just it’s just a immensity of tubings you know how we use determines for IVs in it that in that’s backwards so like gages are backwards right like a 20 gauge is smaller than a wait let me say that again 20 approximate is greater than a 24 measurement like so estimates like this smaller the smaller the amount the bigger the diameter so French’s is normal “the worlds biggest” the figure “the worlds biggest” than that limiter so like 8 to 12 French is like this size and I have a picture of and like 14 to 16 French is those those thicker ones that you look with the suction and then when you’re um when you’re quantifying to lay in a gastric tube this is how they tell you to measure it so like you’ll take a tube like this and like keep the end of it after xiphoid process and they took time to turn their brain and you pull it up to their ear and supported it there and then go to the tip of their snout and then you harboured it there and you consider there’s this these tubes are March in centimeters and wherever you’re possession it when you measure that that’s how far you just wanted to like persist it in but you don’t to go farther than where your that is so you various kinds of recognize that with tape or something and then you positioned it you don’t go past that notes that you situated the tape on and slipping that’s where nasogastric exclusively to the xiphoid process nazo duodenal they actually say to the to the navel except inserting knees and waddles kind of like a special thing that like your bible doesn’t even go over so you don’t really need to know that but just know like for nasogastric that’s how we amount is the notes that you live to the xiphoid process yes precisely that’s that might be on my next thing but yes so um one of the major points that we’re talking about today is that the widow owns the best way to identify or to confirm that you have the tube in the right place is by x-ray that’s really like the one and only like total confirmation there’s other ways to yes so you can do pH is like the second best and and it’s easier than hauling the x-ray machine into the patient’s chamber every four hours but the best way is definitely by by x-ray so so here yeah so um so when you’re inserting it you know you’re gonna look for that case of videotape that you put on the tube so you don’t go past the case of strip and then once you think you have it in the chastise field then you do aspirate a little bit of the the liquors and test the pH so this is just so we we know what we’re like we think we’re in the freedom region we want to test it before we go to x-ray and then if we do get the right pH like I’m trending in the belly and okay like I exactly the pH and it’s 3.0 okay I think in this stomach now let’s take them to x-ray and confirm that it is in the tummy and then you can’t use it you can’t framed anything through it until you get that x-ray so even if the doctor says like I need him to get this remedy through his NG tube stat like you can’t utilization it until you get that x-ray make sure it’s in the right spot because uncle we’re scared of is it going into someone’s lungs a intentional person is gonna choke and restraint when you’re arrange in someone who’s like semi-conscious they may not show any signs if you’re lay it down there their lungs so you you can’t who’s like you have to the doctor has to figure out another if they can’t take it orally and it can’t be crushed to go down there to the doctor has to figure out another way to give them drug so they’re gonna have to like seek a non sustained secrete use of it yeah oh yeah sorry so I reckon I have a slide on this but um so you’re gonna use one of those immense okay my slide is like two apart but I yeah I’ll go over that so formerly verified by x-ray then you can mark the tube with with strip which you kind of previously did but you’re stigmatize it like for good with videotape or like a sharpie or something and you’re charting it in the chart you say like that I slipped this tube and it’s at this numerous centimeters in and then a lot of old school nannies will use an auscultation procedure where they’ll when they want to check if the tubes in the best place not initially just like when they go to use it to give a matted or something they’ll exploit a syringe and inject breeze through it and while they’re injecting the breath they situated their stethoscope to in their tummy and listen and your twisted little singing for suds like like it like if you’re like gastric acid like it’s blowing foams from the air positioned so some wet-nurse I still do that but it’s not best pattern and it’s not recommended so don’t do that oh yeah they I want beings do it all the time that’s how people did it for years and times and years so it’s not like they’re like crazy but it’s just not it’s not best rehearse like we’re not teaching that anymore yeah well and the thing is it’s way faster than getting on the pH divests or find the pH divests or like you know it’s just the whole pH thing it makes longer and nannies don’t have a lot of time so if it’s easier for them to do that they might do it but just know that’s the wrong way so a good point so yeah no you’re absolutely right so actually if they are taking antacids it might be like four to six and I didn’t I didn’t even employ that in my painting because I always thought it was like kinda confusing but but yeah you’re right so if they were on on antacids you have to know ahead of time of that and then when you if you get a pH at five but they’re on antacids you’re like okay it’s okay so I think what the book says it’s like looks like four to six it’s like what it are now in the stomach if antacids but the thing is when you do check pH you’re supposed to do it at least an hour after remedies so it’s possible that the antacids could still be in there running but you’re supposed to always check pH after at least an hour after you’ve given two medications so that it doesn’t interfere with it picture the first wagon I suspect they I think they probably mmm I think they probably would have Becht intestine all but I don’t know for sure I don’t know if they’re like processed before they legislated the pylorus I’m sorry I don’t I don’t know so we at least an hour after drug government exactly any prescription if you if you leave any medication and then you need to check the pH you’re supposed to wait an hour after any drug before you’re checking the pH so the pH confirmation is the second most reliable method so the x-ray is our number one tool to make sure it’s in the right place and then this is the next acceptable lane to demonstrate the two dishes minute and this is because you’re gonna get the x-ray first but then you’re gonna need to frequently check while this person is on to peds you need to like regularly check to make sure it’s in the privilege recognise you need to check it before you devote an periodic feeding it to check it every eight hours for cyclical or ceaseless feedings and then prior i don’t even articulate it on there prior to omit afford a medication so you’re gonna want to make sure it’s in the claim spot and then PRN still like if you hear come to the patient’s room and like you see that it’s like two centimeters further out or something then it’s supposed to be it might be okay like you might be able to time predict vance it but you want to check the pH to see like what area you’re in and so to do this which I think was one of the issues I have an answer yet so you’d utilize one of those gargantuan syringes and you’d infuse 30 ml of air and that mention that reddens out any like formula that’s still in the tube like say say they’re still on the tube feeding you go to give them the remedy the tube feedings been going there’s no formula in the tubing you slammed the spout off and then you just administer air to clear the tube of the formula and then you ask right back time 510 MLS put in a little medicine cup and then you take your little like there’s like a would be like a little not file but a little like I don’t know what to call it where the pH deprives but like the thing where they keep the pH strips it has like the they cook the key on it you just take the deprive and trough it in for however long it says and then compare to the little key and it’ll tell you what the pH is oh and also you’d want to assess the appearing of the aspirin and so the gastric is going to be and I don’t have a picture I would try to picture this but kind of a clear greenish yellow for the gastric and oranges Brown for the intestinal oh here’s a picture of that the test divests so yeah so you dip the strip into the cup and compared to the color chart and then gastric “wouldve been” 1.0 to 4.0 and intestinal 70 or they’re on antacids probably maybe a little higher for gastric okay so checking for gastric residual volume so this let me just start by saying there’s a reason it’s called gastric residual publications we don’t ever do this on the duodenal or jejunal tubes since they’re overstepped the pylorus they’re like in a small plug in an bowel small intestine if you try to pull back too much like you can do the fight of 10 MLS to get the pH but if you try you too much it’s just gonna suck against the wall of the entrails in Custis you trauma so we don’t check residual and besides that like the intestines aren’t like a harbouring tank like the belly is fluid it is therefore just doesn’t precisely doesn’t entered into with with what we’re doing to check residues if it moves past if it’s a transcriber or two so this is only for gastric liquid so we were checking prior to an periodic feeding or every eight hours of endless so it’s kind of like then checking the page two same thing we’re controlling the the pH before I want I represent feedings in every eight hours if it’s ceaseless so what you do is you time employed that gigantic syringe on and you merely back out and you know it’s fine it might be more than that we’ll fill that syringe draw back and exhaust it pull back and evacuate it see how much you have and if it’s more than 150 ml then we’re kind of worried that they’re not emptying their tummy as quickly as they should be and I employed assure equipment policy because there’s actually different asks on this there’s not one standard ask my Hospital says 200 is the like the thing that you if it’s more than 200 is when you like brace the feeding and apprise the doctor your notebook actually also said 200 but the last lecture that I was like various kinds of facing my like Scirocco said 150 but but I mean your work also says like realize equipment programme because it can change but about 150 to 200 gastric residual is where you’re going to start to question and like okay I don’t think they’re exhausting their belly fast enough or we’re feeding in too much food or whatever so the first thing you do though is you precisely return that to the patient just whatever was there you propagandize it back in regard the feeding if it’s on continual if they’re on perpetual costs or if you were about to give them an occasional feeding you halting the feeding tell the doctor they’re just gonna say okay encumber it for an hour and recheck that’s kind of like a standard policy and then you recheck and if it’s still that high there are enough older feeding and like trying to figure out maybe do some diagnostic tests figure out what’s wrong because there’s some kind of delayed gastric emptying going on that they’re not sure what’s going on and if it’s less than 150 so they have processed some of it when you recheck then the doctor probably give you an order to restart the feedings but he’s going to change the rate and make it slower so because after so after an hour it’s less than 150 you realize okay they are processing some of it there’s not managing it as fast as we thought they would so we can still feed them but only not a little faster as we were yes yes good question wait good question I don’t know don’t worry down guy so I don’t know that I would need perhaps you don’t I don’t know and I don’t think about what I was speak off with the freezing and the responses to that I can the reason why I can I can email you guys about I don’t know the answer to that did anyone speak that are you time checking yeah but if they’re not like if they have like gastroparesis or something and they haven’t processed any of it I would think that you do I don’t yeah I don’t think you would set it back in that doesn’t make sense because you’re just frame them at risk for like Raja Brahman again I can get back to you I don’t know I don’t know the answer to that I would just be a guess if I “ve told you” but I convey I would guess that you don’t yeah it’s never happened to me like I’ve never had to cross that bridge yes there’s five to ten milliliters that you were talking about don’t depict more than that back to the pH combination is what you intended like collapse yeah yeah yeah or click yeah we’re collapse like the bowels yeah so like it is okay to ask for a tiny bit you’re going to want to before you return any medication or feedings or whatever through a duodenal or jejunal tube yeah but exactly that little bit you’re not going to try to like back out everything that’s in there as you are able to on the gastric residues you can actually pull back egg nuts in there because the stomach’s just a impounding tank you’re not going to like definitely collapse it oh you know okay so maintaining the patency of your tube so for perpetual feedings you just wanted to redden the two with 30 ml an hour 30 ml zone sea sorry at least every four hours but your guys aren’t you probably won’t be actually responsible for this because most feeding tubings are on spouts that have a water side so typically there’s a feeding area and a spray slope and usually the pump will automatically do the the spray redden for you and it’ll be like 25 ml as an hour or something it’ll be in the doctor’s order so like the doctor has the say all fixed up nice now for how much formula per hour and then how much spray per hour and then as long as you set up the shoot right it’s reddening it for you so for continuing or cyclical feedings you’re not actually going in there and flushing it every four hours although technically you probably will be more often because you’re robbing to go in there with prescriptions to say you’re probably end up rushing you regardless but just for to maintain patency you’re probably not going to go in every four hours and do this because you’re most likely you’ll have a water tubing on your spout that’ll do it for you and then so if you’re on if someone’s on occasional feedings so again that’s probably more likely individual like in the home setting maybe before and after each tubing feeding so 30 MLS grit before give the feeding 30 MLS of irrigate after and that merely empties everything out and then before and after drug administration administration and surely heated ocean is better because it can help dissolve any little particles that didn’t crush very well and then after checking gastric residual volume so after we pull back that 5 to 10 MLS check the pH then we want to flush it with ocean so everything just kind of continues it cleared out because anytime anytime you you try to aspirate you’re attract the fluid back and it’s just like it’s you’re set at risk for clotting when you’re attract stuff into the – so you always want to flush it like after checking residues or after checking the pH yes yeah it was possible to I mean based on the patient’s fluid needs yeah like the doctor might order a good deal for a dehydrated patient or a little bit for someone that’s like perhap sucking a little bit of water I don’t know but yeah I entail the it’s stipulate hydration if if they’re able to if they’re able to safely like suck liquors yes it’s just extremely unlikely because the reason that they have a tubing is probably because they can’t so I don’t know like in the case of vehicles of like a anorexic case they might be drinking water but they won’t merely won’t applied meat in their cheek and so they might have a feeding tube but they’re still drinking water they’re able to swallow privilege they just don’t they don’t they won’t apply menu in their cavity yeah okay and then so if the tube becomes clotted say you go to give a drug and and you try to you’re trying to flush it with that 30 ml of water more before you give the medication and you meet defiance so well the first step is flushed with 30 ml of spray so you various kinds of like simply use a little gentle pressure see if you can with that like totally just trying to jostle it in like a little gentle pressure see if you can kind of precisely unlock the tube if that’s ineffective you can use carbonated beverage which the what the book said it’s they use cranberry juice oh really okay well I’m I was using my old-time med surg notebook from when I was in harbouring academy and they did educate us this and I check harbours like steal coke through which it was so weird the first time I visualized it but so your bible said not to use carbonated at all or you just stop pertaining know there is a special kit that they use for that oh yeah like anything maybe that’s like a newer thing I don’t know about love my med surg record taught us this what people set soda yeah I thought it was still an acceptable acquisition but I guess what she’s saying is probably now they have actual like things that you can push through that that’s gonna unclog it like an actual like like dictate for whatever that I don’t even know what it’s called because I’ve never heard of it but yeah I don’t know ours in it so we actually could cook down yeah okay that’s what like yeah they’re various kinds of like propelling it yeah that’s what we do in my hospice still so if it’s I don’t I want so I guess that maybe the clot-busting thing is like elevated but I know my med surg record which is only like four or five years old like said this is an accessible rehearse okay so wherever possible you want to use liquid drugs instead of crush tablets so you can be a good patient advocate now a good deal of remedies are now in liquid use that medical doctors might still have an oral medication to you know now they’re NG tube or something maybe the doctor kind of impeded the same drugs on their roster and you realize like oh actually like we can you settled that drug let’s kept that in liquid word and then we can positioned it through their hurting so so certainly look out for things like that the suppres tablets plainly are going to clog the – faster than a liquid drug so that’s the reason and don’t concoction prescriptions with the feeding formula like if you humiliate the meds like don’t mix it with some of this formula and then like thrust it through the tube like we just mashed it and we mingle it with heated sea so like you’ll have a little like remedy bowl with your crushed pills and you’ll kind of squirt a little warm water in there mix it around with the syringe and then draw it back up and then that’s how you inject it yeah it’s just yeah basically it’s just cause like vanquish the pills like doesn’t always labor as well as you want so you various kinds of like mixed up with warm water push it down a little bit kind of like make it as tiny smallish corpuscles as you can and then ensure the tablets are safe to mash so we kind of already this but extended-release want to make sure you’re not crushing an extended-release tablet and then I’m just some like general Nursing guidelines for g-tubes or J tubings so that’s these are the ones where it’s going to be like implanted through their abdomen so you’re gonna want to assess the insertion site site extremely if it’s a newly placed one that’s when you have the higher risk for infection and after they have it for a few months it kind of their body kind of adapts to it but right right after it you want to clearly be assessing it routinely for ratifies of infection and you just wanted to revolve it 360 magnitudes every day and that moves sure you actually don’t want that like embedded into their skin like you don’t want to grow into it you require the tube to always is just like movable so you want to be able to revolve the G tube or the JT if you don’t want their skin to grow around it and embed it like in one place that’s just I think it’s a risk for infection and also like I think it’s tugged or something it’s going to justification damage so you want to actually rotate it make sure it’s movable like in that hole and then you’re gonna cover the site like around it with the sterile separate gauze and vary that daily or PRN they might need most frequently asked alterations like freedom after it gets put there’ll be a little more drainage when they’re new lean a split gauze is um I don’t know if you guys have verified it’s like a square it’s like a square piece of gauze been fucking loving this big and it has like a piece like simply halfway through part of it so you can like situate it around I wish I had like two examples but so you can like set it around the hole and it still kind of EXO cross abdomen and so it’s not like you don’t need to like it’s not a infertile process to like touch around the g-tube or anything but we just want to set sterile gauze around the part that you know where it’s going into their their body if you do ever need to clean this place you can just if it’s a soothed you know it’s not a super fresh one if it’s super fresh I believed to be simply want to use like infertile saline to scavenge around it if it’s it’s been there a while you can use soap and irrigate to clean around it if it’s getting a little surly so this is this is like what a luggage of formula looks like so like you know you don’t have a picture of the sheet in here but the page will be laying down here and have their like g-tube or NG tube or whatever connect it to tubing and they would come up to this bag and and so this bag this violet thing fastens off and it’s just this large opening where you sounds open the cans and like for that drum the formula in and you exclusively want to add four hours of feeding to the bag at a time so even though these luggage you only alter every 24 hours but you so use it for 24 hours but you don’t positioned the whole day’s worth of formula in it at once you exactly supplement four hours of heating at a time so it starts to get low-pitched it’s like about this low pour in some more and that’s for bacterial swelling avoidance but I make the stomach is not a sterile environment you know it’s just a clean environment but we still don’t want to we don’t want to minimize the risk of bacteria that we interviews into it and then I couldn’t find a illustrate but commonly there’s there be a ocean back hanging here sir via another purse that looks very similar to this right here and then you have the formula bag in the spray back and then both going through the spout into the patient okay so we’re going to go into the complications of entero nutrition and various kinds of like the hold intervention that you would do to prevent or resolve the complication we tell them okay so pulmonary intention is probably a number one complication of Antero meeting so the elevation the formula is thick-witted in calories and sugar it like requires a good emergence are good medium for bacteria to grow and then so if there is some bacteria you know when your gut and then you aspirate it it’s kind of makes you at increased risk to get pneumonia or some other kind of infection so preventive measures are things we already talked about like initially when you applied it in you’re going to get the x-ray and make sure it’s in the right place before “youre using” it you know check the pH before you get a drug or generate an occasional feeding or every eight hours if it’s continuous and then you want to keep the head of the bed if tolerate and keep the head of the bed at least thirty severities so staying with like goal prudences for someone like with dysphasia and you demand you know how you want to keep them up if when they’re eating so same thing you want to keep their head of the berthed up during continuous and for at least 30 hours after occasional gobbling and then if you do have to lower the head of the bunked like you’ve had to do this at our clinical place sometime select alter a diaper or something so you really pause the feeding and do whatever care you need to do and with the mecha diarrhea so I kind of already talked about this the hyper osmolality of the formula attracts in a lot of water into your method so if we’re feeding them a little too fast so there’s not digesting it a little faster as we thought it’s gonna pull in all that water and reason diarrhea one of the things you can do intervention wise is and probiotics because maybe it’s not quite for I predict yeah this is different cause of diarrhea but if it’s be from some kind of GI bug you were able to computed probiotics they are likely need antibiotics if there is an actual GI infection but if “its just” from feeding too quickly they’re not tolerating it they’re going to slow their proportion down based on the doctors order and there’s different there’s different types of formulas there’s like hypertonic formula sparkler attain it isotonic so they might the doctor might convert how strong the formula is and then you want to wash the formula bag every eight hours and then change it every 24 hours so we talked about the changing the suitcase every 24 hours but you want to wash it every eight hours just bath it out with ocean it doesn’t have to be like sterilized but just cleansed out with water eight hours so on the other side of that you’re not if you don’t get the diary you might get funds to patient and so some things for that would be the changing formula with more fiber they are likely need more ocean evens perhaps they’re a little bit dehydrated or free spray if they’re if they’re drinking liquors you can give me more liquors to booze and if they’re if it’s somebody that’s able to ambulate you’re going to want to get them up and get a-movin more because that’s probably one of the reasons for their constipation so to Baku gene this is actually I take it back when I said the desire was one of the click the main this would be this is the thing that happens the most with YouTube this is occlusion or chokes so we talked about how do you maintain the patency you want to flush it with 30 ml of water before before they’re bitten feedings before my before and after prescriptions and then your spray blush if it’s on a shoot will do that for you so perhaps due to meds not being added to be subdued so you want to make sure you get the fine grains and you’re vanquish the pills and mingle it with the heated sea write dissolve it make sure you’re irrigating before and after medications we’re not desegregating prescriptions with formula like we talked about we want to push for the liquid forms of prescriptions instead of capsules and I already said blossom to displacement so if someone’s puking or coughing a lot of times that’ll pull up the tube in it you either wrinkles in their GI tract or it actually comes all the way up and can go in their lungs so if it’s just if it’s just a little like you precisely notice it’s one thing pair centimeters out your laboratories and “ve been trying to” like reinvent it and check the pH if it’s significantly out if it’s there’s no like figures on this but if you if you feel if you have good suspicion that this tube is not in the right place it’s like enormously out you want to get get and especially if they have any manifestations of respiratory distress or or their coughing restraint whatever so delay gastric emptying so this is like we talked about residuals and if they’re having too much residual maybe they don’t they’re not emptying their gut as fast as they should be which could be from gastroparesis or exactly their peristalsis is slowing down because they’re a portable the doctor might tell a prokinetic medicine that helps empty their gut the most frequent one that I’ve seen is metoclopramide which is Reglan so they might administer that and what that drug does is it’s kind of an anti not I don’t know if you guys are more likely read it brands einon’s also but the road it is for Antonacci but the course it manipulates is it vacates our stomach faster so in the case of Naja it’s emptying that that battery-acid out of your tummy so the battery-acids not to stay here compiling me nauseated but for this effect it would be pushing the formula down faster so it’s not your meridian and then the other thing was like maybe they are necessary a duodenal tube instead of a gastric tubing if they’re having all this gastric flowing like stay in their stomach perhaps they need to pass that by loris and just go all the way to bowels so electrolyte imbalances so it could be caused by by diarrhea you know if they’re having a diarrhea for my speeding them too fast they’re gonna get electrolyte imbalances if they’re just dehydrated because we’re not sacrifice them enough or if they have some kind of chronic liver or renal infection so you’d be monitoring their electrolytes daily that pretty much happens automatically in hospices you’re always reaping the blood and Lauren administer free spray which are capable of just be like whether they’re booze the spray or you’re just urge additional sea that’s not you know the spouts demonstrating them a certain amount that aimed up doctor lineups that you push this much free sea right now thunder – and then they’re completely electrolyte says eat it so merely you probably see if you will get an IV potassium or or in this case you can do it through their NG tube if it wasn’t that critical but you must be monitoring their electrolytes and then replacing them recurred so refeeding syndrome so this is something that can happen to somebody that’s chronically chronically malnourished are electronically not getting enough food and then all of a sudden some that hasn’t had enough food in a long time all of a sudden gets a bunch of menu so what happens it’s in like a famine State is your body like your body insulin and it stops stuff it’s not working because you’re not and so when you then start eating food all of a sudden you get this touch of insulin it hasn’t really acted in a very long time and it’s called it’s gathering the nutrient into the cells but it’s also plucking a knot of electrolytes out of the out of your blood just like really quickly depletes your blood of all these electrolytes velocity Mia hypokalemia pebble magnesia it’s very dangerous I intend well such a quick deepen that it could be bad for your feeling or your lungs so that’s definitely one of the reasons we likewise advance feedings really slowly but especially for someone who like is anorexic and has been in a starvation State or someone was you know found in their home and brought to their hospital they haven’t eaten in weeks or whatever for whatever reason if you know they haven’t really eaten in a very long time you’re gonna be really careful and breakthrough the formula awfully very slowly to make sure you don’t establish this refeeding syndrome and then just like a memo about in Terrell versus parenteral if someone’s not able to eat their own food our first choice is obviously inteiro parent a statute role is truly if their GI tract isn’t working there’s a lot of benefits to entero it has less less cases of infection or sepsis and downplays the hyper med of all the response to trauma which I apparently mimic the cases because I can’t think of how to describe that let’s see downplays oh so if you have trauma and then your your person needs to go into like a hyper metabolic country then you’re a more able to cope with it it maintains your intestinal design and serve so your intestines still know how to work it’s safe or less expensive and it’s easier to do okay so I have short-lived castigates you guys I have I got 3 places left and I don’t know if these were on your thing I might have had these last night so I exactly would like to speak about your nutrition paper so you’re gonna have a case study do this quarter it’s due on the 26 th of May I conclude and it’s going to be it’s a it’s like two parts it’s a newspaper and then like six appendices that are kind of like all these different kinds of assessments and analyze ations and it’s all in your syllabus so and I’m not going to go through every single page but mostly you’re going to focus on one of your patients that you’re seeing in clinicals and do all these assessments on the get their nutritional expense like a full nutritional evaluation there’s a marry other like that you go to like the myplate.gov website and find what they’re like you know best food program is and I can I do these like these little projects and then after you do all those like analyzation things then you write it’s a four to five sheet newspaper and it’s kind of like a summary of like everything you found out assessing them and then too recommending what modifies could be made based on best tradition okay yeah so 45 pages of text intro you summarized their diet and related their problems and then make recommendations and the the syllabus has a rubric like very clearly like asks like exactly what we’re looking for and it also has for all the appendices it has a template for all of them so what I was telling my clinical radical is like just to introduce all those like templates into clinicals like the week that we’re doing this project and time various kinds of like abuse those to like merely drop down all your memoranda and then you can take it home and category it all over now the nutrient injector only based on what a morning so there’s a there’s a cluster of different there’s one that’s like a 48 -hour diet remembrance well no it’s just you’re just gonna ask your patient when you get there like why’d you eat the last 48 hours are you able remember and they may not be able to remember well I was likewise telling my students like whatever week you guys are picking your patients like me try to have a patient that can converse with me yeah because if you have something that’s just altogether out of it you know you might project might be easier but you’re gonna get any information so it’s fine I’m gonna be a very thorough paper so yeah so there’s a bunch of things one of the things it’s just like a nutritional evaluation you are familiar with like their physical rating you are familiar with do they have cool skin the government has like thin whisker and one of them is the 48 hour food recall one of them is like going on to the MyPlate website and like finding out they’re like plan for how many calories they’re supposed to have theirs and their specific instructions for all these things so like don’t worry if you don’t know what I’m talking about Oh so here’s to addiction so client state assessment so that’s the full like physical appraisal are concentrated on things that might point to malnutrition 48 -hour food reminisce which is you just asking them if they can remember what they eat for the past six snacks or whatever the last two days nutrition history you know did they have any GI maladies or compulsive eating deficiencies oh the client health assessment includes labs – like their if the government has low-toned potassium or whatever you’re into a nurse charge program so I’m assuming other coaches are doing the same but like my own group not gonna have a care plan that week because why would you have to so the care plan I think there’s I think it has two diagnosings on it you two diagnoses with the impact and interventions Oh daily meat programme worksheet from choosemyplate.gov and then a nutrition analysis which is like there’s a template for that you know that’s not something that you have to figure out yeah you shouldn’t be specifically targeted well it’s gonna be like on this patient that you’ve already done all this like assessment for it right right but if they have oh no so it’s sorry so it’s trying to focus on their nutritional regime yeah I convey yeah which will be hard because I necessitate it might be hard to come up with two identifications that are both nutrition associated but I symbolize I I guarantee hospital cases using them I convey it yes and no I symbolize I envisage I think that everyone has a lot of nutritional troubles in the hospital more like what I told my case Burke my students was just like kind of want to stay away from the like 20 year olds that just got like an appendectomy I symbolize like but everyone like for the most part everyone the hospital has a lot of problems and probably multiple nutritional ones and that might be why they’re there or they might have nutritional questions from their conditioning or whatever

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