Page 424 - Nutrition Essentials for Nursing Practice

412 U N I T 3 Nutrition in Clinical Practice

NURSING PROCESS: Enteral Nutrition Support

V ince is 48 years old, 6 ft tall, and has weighed 170 to 175 pounds throughout his adult life. Two
weeks ago, he was admitted to the intensive care unit after an industrial accident caused first- and
second-degree burns over 20% of his body. He was initially fed via a nasogastric tube and then started on
an oral diet. Vince was only able to achieve 40% of the calorie goal set by the dietitian, so he has reluctantly
agreed to be fed by tube for 8 hours during the night to supplement his daytime oral intake.

Assessment

Medical–Psychosocial History ■ Medical history, such as diabetes or GI disorder

Anthropometric Assessment ■ Medications that may affect nutrition
Biochemical and Physical
Assessment ■ Current treatment plan

Dietary Assessment ■ Level of tube-feeding acceptance, including fears or apprehension
about being tube fed during the night

■ If Vince may need a tube feeding after discharge, assess living situation,
such as availability of running water, electricity, refrigeration, cooking
and storage facilities, employment, social support system, and financial
status

Height, current weight, body mass index

Percentage of usual body weight

■ Check laboratory values—prealbumin (if available), hemoglobin, hemat-
ocrit, glucose, electrolytes; other abnormal values for their nutritional
significance

■ Check tube for proper positioning; check external length of tube every
4 hours to monitor tube placement

■ Observe for signs of fluid overload

■ Ask if the client has any physical complaints associated with oral food
intake or tube feeding, such as nausea or bloating

■ Observe abdomen for distention

■ Measure residual volumes

■ How many calories and how much protein are being provided via the
tube feeding?

■ Do the nocturnal tube feedings affect the amount of food consumed
orally during the day?

■ Is protocol being followed for administering the tube feeding and docu-
menting administration and tolerance?

■ Is Vince able and willing to learn how to use tube feeding at home if
necessary?

Diagnosis

Possible Nursing Diagnoses Altered nutrition: eating less than the body needs r/t inadequate calorie
replacement to meet metabolic needs