Question

WHAT IS the pre-test, tutorial and post-test for the following 3 skills modules:

• Enteral Tube Feedings

• Vital Signs

• Urinary Catheter Care

Answer 1

Types of enteral feeding

According to the American College of Gastroenterology, there are six main types of feeding tubes. These tubes may have further subtypes depending on exactly where they end in the stomach or intestines.

The placement of the tube will be chosen by a doctor based on what size tube is needed, how long enteral feeds will be required, and your digestive abilities.

A medical professional will also choose an enteral formula to be used based on tube placement, digestive abilities, and nutritional needs.

The main types of enteral feeding tubes include:

• Nasogastric tube (NGT) starts in the nose and ends in the stomach.
• Orogastric tube (OGT) starts in the mouth and ends in the stomach.
• Nasoenteric tube starts in the nose and ends in the intestines (subtypes include nasojejunal and nasoduodenal tubes).
• Oroenteric tube starts in the mouth and ends in the intestines.
• Gastrostomy tube is placed through the skin of the abdomen straight to the stomach (subtypes include PEG, PRG, and button tubes).
• Jejunostomy tube is placed through the skin of the abdomen straight into the intestines (subtypes include PEJ and PRJ tubes).

NGT or OGT

Placement of a nasogastric tube or orogastric tube, while uncomfortable, is fairly straightforward and painless. Anesthesia isn’t required.

Typically a nurse will measure the length of the tube, lubricate the tip, place the tube in your nose or mouth and advance until the tube is in the stomach. The tube is usually secured to your skin using soft tape.

The nurse or doctor will then pull some gastric juice out of the tube using a syringe. They’ll check the pH (acidity) of the liquid to confirm that the tube is in the stomach.

In some cases, a chest X-ray may be needed to confirm placement. Once placement is confirmed, the tube may be used immediately.

Nasoenteric or oroenteric

Tubes that end in the intestines often require endoscopic placement. This means using a thin tube called an endoscope, which has a tiny camera on the end, to place the feeding tube.

The person placing the tube will be able to see where they’re putting it via the camera on the endoscope. The endoscope is then removed, and placement of the feeding tube may be confirmed with aspiration of gastric contents and X-ray.

It’s common practice to wait 4 to 12 hours before using the new feeding tube. Some people will be awake during this procedure, while others may require conscious sedation. There’s no recovery from the tube placement itself, but it may take an hour or two for the sedation medications to wear off.

Gastrostomy or jejunostomy

Placement of gastrostomy or jejunostomy tubes is also a procedure that may require conscious sedation, or occasionally general anesthesia.

An endoscope is used to visualize where the tube needs to go, and then a tiny cut is made in the abdomen to feed the tube into the stomach or intestines. The tube is then secured to the skin.

Many endoscopists choose to wait 12 hours before using the new feeding tube. Recovery may take five to seven days. Some people experience discomfort at the tube insertion site, but the incision is so small that it typically heals very well. You may receive antibiotics to prevent infection.

Enteral vs. parenteral feeding

In some cases, enteral feeding may not be an option. If you’re at risk for malnutrition and don’t have a functional GI system, you may need an option called parenteral feeding.

Parenteral feeding refers to giving nutrition through a person’s veins. You’ll have a type of venous access device, such as a port or a peripherally inserted central catheter (PICC or PIC line), inserted so you can receive liquid nutrition.

If this is your supplementary nutrition, it’s called peripheral parenteral nutrition (PPN). When you’re getting all of your nutritional requirements through an IV, it’s often called total parenteral nutrition (TPN).

Parenteral feeding can be a life-saving option in many circumstances. However, it’s preferable to use enteral nutrition if at all possible. Enteral nutrition most closely mimics regular eating and can help with immune system function.

Possible complications of enteral feeding

There are some complications that can occur as a result of enteral feeding. Some of the most common include:

• aspiration, which is food going into the lungs
• refeeding syndrome, dangerous electrolyte imbalances that may occur in people who are very malnourished and start receiving enteral feeds
• infection of the tube or insertion site
• nausea and vomiting that may result from feeds that are too large or fast, or from slowed emptying of the stomach
• skin irritation at the tube insertion site
• diarrhea due to a liquid diet or possibly medications
• tube dislodgement
• tube blockage, which may occur if not flushed properly

There are not typically long-term complications of enteral feeding.

When you resume normal eating, you may have some digestive discomfort as your body readjusts to solid foods.

Who shouldn’t have enteral feeding?

The main reason a person wouldn’t be able to have enteral feeds is if their stomach or intestines aren’t working properly.

Someone with a bowel obstruction, decreased blood flow to their intestines (ischemic bowel), or severe intestinal disease such as Crohn’s disease would likely not benefit from enteral feedings.

What are vital signs?

Vital signs are measurements of the body's most basic functions. The four main vital signs routinely monitored by medical professionals and health care providers include the following:

• Body temperature

• Pulse rate

• Respiration rate (rate of breathing)

• Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

What is body temperature?

The normal body temperature of a person varies depending on gender, recent activity, food and fluid consumption, time of day, and, in women, the stage of the menstrual cycle. Normal body temperature can range from 97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or Celsius) to 99 degrees F (37.2 degrees C) for a healthy adult. A person's body temperature can be taken in any of the following ways:

• Orally. Temperature can be taken by mouth using either the classic glass thermometer, or the more modern digital thermometers that use an electronic probe to measure body temperature.

• Rectally. Temperatures taken rectally (using a glass or digital thermometer) tend to be 0.5 to 0.7 degrees F higher than when taken by mouth.

• Axillary. Temperatures can be taken under the arm using a glass or digital thermometer. Temperatures taken by this route tend to be 0.3 to 0.4 degrees F lower than those temperatures taken by mouth.

• By ear. A special thermometer can quickly measure the temperature of the ear drum, which reflects the body's core temperature (the temperature of the internal organs).

• By skin. A special thermometer can quickly measure the temperature of the skin on the forehead.

Body temperature may be abnormal due to fever (high temperature) or hypothermia (low temperature). A fever is indicated when body temperature rises about one degree or more over the normal temperature of 98.6 degrees Fahrenheit, according to the American Academy of Family Physicians. Hypothermia is defined as a drop in body temperature below 95 degrees Fahrenheit.

About glass thermometers containing mercury

According to the Environmental Protection Agency, mercury is a toxic substance that poses a threat to the health of humans, as well as to the environment. Because of the risk of breaking, glass thermometers containing mercury should be removed from use and disposed of properly in accordance with local, state, and federal laws. Contact your local health department, waste disposal authority, or fire department for information on how to properly dispose of mercury thermometers.

What is the pulse rate?

The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood. Taking a pulse not only measures the heart rate, but also can indicate the following:

• Heart rhythm

• Strength of the pulse

The normal pulse for healthy adults ranges from 60 to 100 beats per minute. The pulse rate may fluctuate and increase with exercise, illness, injury, and emotions. Females ages 12 and older, in general, tend to have faster heart rates than do males. Athletes, such as runners, who do a lot of cardiovascular conditioning, may have heart rates near 40 beats per minute and experience no problems.

How to check your pulse

As the heart forces blood through the arteries, you feel the beats by firmly pressing on the arteries, which are located close to the surface of the skin at certain points of the body. The pulse can be found on the side of the neck, on the inside of the elbow, or at the wrist. For most people, it is easiest to take the pulse at the wrist. If you use the lower neck, be sure not to press too hard, and never press on the pulses on both sides of the lower neck at the same time to prevent blocking blood flow to the brain. When taking your pulse:

• Using the first and second fingertips, press firmly but gently on the arteries until you feel a pulse.

• Begin counting the pulse when the clock's second hand is on the 12.

• Count your pulse for 60 seconds (or for 15 seconds and then multiply by four to calculate beats per minute).

• When counting, do not watch the clock continuously, but concentrate on the beats of the pulse.

• If unsure about your results, ask another person to count for you.

If your doctor has ordered you to check your own pulse and you are having difficulty finding it, consult your doctor or nurse for additional instruction.

What is the respiration rate?

The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing.

Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute.

What is blood pressure?

Blood pressure is the force of the blood pushing against the artery walls during contraction and relaxation of the heart. Each time the heart beats, it pumps blood into the arteries, resulting in the highest blood pressure as the heart contracts. When the heart relaxes, the blood pressure falls.

Two numbers are recorded when measuring blood pressure. The higher number, or systolic pressure, refers to the pressure inside the artery when the heart contracts and pumps blood through the body. The lower number, or diastolic pressure, refers to the pressure inside the artery when the heart is at rest and is filling with blood. Both the systolic and diastolic pressures are recorded as "mm Hg" (millimeters of mercury). This recording represents how high the mercury column in an old-fashioned manual blood pressure device (called a mercury manometer or sphygmomanometer) is raised by the pressure of the blood. Today, your doctor's office is more likely to use a simple dial for this measurement.

High blood pressure, or hypertension, directly increases the risk of heart attack, heart failure, and stroke. With high blood pressure, the arteries may have an increased resistance against the flow of blood, causing the heart to pump harder to circulate the blood.

Blood pressure is categorized as normal, elevated, or stage 1 or stage 2 high blood pressure:

• Normal blood pressure is systolic of less than 120 and diastolic of less than 80 (120/80)

• Elevated blood pressure is systolic of 120 to 129 and diastolic less than 80

• Stage 1 high blood pressure is systolic is 130 to 139 or diastolic between 80 to 89

• Stage 2 high blood pressure is when systolic is 140 or higher or the diastolic is 90 or higher

These numbers should be used as a guide only. A single blood pressure measurement that is higher than normal is not necessarily an indication of a problem. Your doctor will want to see multiple blood pressure measurements over several days or weeks before making a diagnosis of high blood pressure and starting treatment. Ask your provider when to contact him or her if your blood pressure readings are not within the normal range.

Catheter Care

• You need to clean your catheter, change your drainage bags, and wash your drainage bags every day.
• You may see some blood or urine around where the catheter enters your body, especially when walking or having a bowel movement (pooping). This is normal, as long as there’s urine draining into the drainage bag. If there’s not, call your healthcare provider.
• While you have your catheter, drink 1 to 2 glasses of liquids every 2 hours while you’re awake.

Showering

• You can shower while you have your catheter in place. Don’t take a bath until after your catheter is removed. This is because taking a bath while you have your Foley catheter puts you at risk for infections.
• Make sure you always shower with your night bag. Don’t shower with your leg bag. You may find it easier to shower in the morning.

You will need the following supplies:

1. Gather your supplies. You will need:
   • Mild soap, such as Dove^®
   • Water
   • 1 Cath-Secure^®
2. Wash your hands with soap and water for at least 20 seconds.
3. Using mild soap and water, clean your genital area.
   • Men should pull back their foreskin, if needed, and clean the area, including the penis.
   • Women should separate the labia, and clean the area from front to back.
4. Clean your urethra (urinary opening), which is where the catheter enters your body.
5. Clean the catheter from where it enters your body and then down, away from your body. Hold the catheter at the point it enters your body so that you don’t put tension on it.
6. Rinse the area well and dry it gently.
7. If you removed your old Cath-Secure, use the new Cath-Secure to attach the catheter to your leg to keep it from moving.

You will change your drainage bag 2 times a day.

• In the morning after you shower, change the night bag to the leg bag.
• At night before you go to bed, change the leg bag to the night bag.

You will need the following supplies:

• A clean washcloth (not one already used for bathing) or a 4”x 4” piece of gauze
• Night or leg drainage bag (whichever one you are switching to)
• 2 alcohol pads

1. Wash your hands with soap and warm water for at least 20 seconds.
2. Empty the urine from the drainage bag into the toilet. Make sure that spout of the drainage bag never touches the side of the toilet or any emptying container.
3. Place the clean cloth or gauze under the connector to catch any leakage.
4. Pinch off the catheter with your fingers and disconnect the used bag.
5. Wipe the end of the catheter with an alcohol pad.
6. Wipe the connector on the new bag with the second alcohol pad.
7. Connect the clean bag to the catheter and release your finger pinch.
8. Check all connections. Straighten any kinks or twists in the tubing.

You may also find it helpful to watch the video below that shows you how to change your drainage bags.

Caring for your leg bag

• The tubing from the leg bag should fit down to your calf with your leg slightly bent. If you have extra tubing, you may need to cut it. Your nurse will show you how to do this.
• Always wear the leg bag below your knee. This will help it drain.
• Make sure to place the leg bag on your calf with the Velcro^® straps your nurse gave you. Use a leg strap to secure the tubing to your thigh.
• If the straps leave a mark on your leg, they are too tight and should be loosened. Leaving the straps too tight can decrease your circulation and lead to blood clots.
• Empty the leg bag into the toilet through the spout at the bottom every 2 to 4 hours, as needed. Don’t let the bag become completely full.
• Don’t lie down for longer than 2 hours while you’re wearing the leg bag.

Caring for your night bag

• Always keep the night bag below the level of your bladder.
• To hang your night bag while you sleep, place a clean plastic bag inside of a wastebasket. Hang the night bag on the inside of the wastebasket.

Cleaning the drainage bags

You will need the following supplies:

• White vinegar
• Cool water

1. Wash your hands with soap and warm water for at least 20 seconds.
2. Rinse the bag with cool water. Don’t use hot water because it can damage the plastic equipment.
3. To decrease odor, fill the bag halfway with a mixture of 1 part white vinegar and 3 parts water. Shake the bag and let it sit for 15 minutes.
4. Rinse the bag with cool water and hang it up to dry.

Follow these guidelines to prevent getting infections while you have your catheter in place:

• Keep the drainage bag below the level of your bladder and off the floor at all times.
• Keep the catheter secured to your thigh to prevent it from moving.
• Don’t lie on your catheter or block the flow of urine in the tubing.
• Shower daily to keep the catheter clean.
• Clean your hands before and after touching the catheter or bag.

Call your healthcare provider right away if you have any of the following:

• Your catheter comes out. Don’t try to replace it yourself.
• You have a fever of 101°F (38.3 °C) or higher.
• You’re making less urine than usual.
• You have foul-smelling urine.
• You have bright red blood or large blood clots in your urine.
• You have abdominal (belly) pain and no urine in your catheter bag.