Question

P. R. a 31-year old woman, contracted an upper respiratory tract infection, developed high fever, and began to experience progressive ascending paralysis. She was admitted to the local hospital, diagnosed with Guillain-Barré syndrome and 10 days later was discharged to home with home health care nurses, from your agency, around the clock. She is intubated and mechanically ventilated. Her VS are 112/68, 134, 12, 101^oF. The placement of her nasal-duodenal tube was confirmed by abdominal x-ray. Her total parenteral nutrition (TPN) was discontinued yesterday and she was started on enteral nutrition (EN). The consulting dietitian calculated P. R.’s caloric need at 2800 calories/ 24 hours because of her fever.

1. Identify and discuss 3 factors that would influence the physician’s decision to place P. R. on EN.
2. Absolute medical contraindications to enteral feeding (EN) are few, and it is prefereable to demonstrate failure of EN than to assume that the GI tract is nonfunctional and initiate TPN. Give 3 example of medical diagnoses for which EN would be contraindicated.
3. Pulmonary aspiration is a risk with enteral feeding, although the risk is substantially reduced with duodenal placement. Identify 4 measures that can be taken to minimize the risk of aspiration.
4. Identify 5 strategies for preventing bacterial contamination of the feeding formula and tubing.
5. Identify 2 indicators that an EN infusion rate is too rapid.
6. The nurse needs to monitor P. R.’s GI response to EN and steroid therapy. Identify 2 observations that need to be recorded, and explain the significance of each.
7. It is common belief that diarrhea with enteral feedings (defined > 3 liquid stools/day) is a natural consequence of EN administration. Discuss whether or not, this is a true statement.
8. Identify 3 factors that could cause diarrhea.
9. As P. R.’s nurse, you are concerned about meeting her needs for fluids, oral hygiene, skin integrity, and activity.
10. Discuss 5 indicators that would help you assess fluid status.
11. The goal related to P. R.’s mouth care is to preserve the oral mucosa and dentition. Identify 3 strategies for providing oral hygiene with an oral endotracheal tube (ETT) in place.
12. What is the rationale for not taking an oral temperature in the vicinity of an ETT?
13. You assess P. R.’s skin every 4 hours. Identify 3 treatment goals in relation to skin/positioning.
14. What 4 strategies will facilitate the expected outcome of maintaining skin integrity?
15. You approach P. R. to begin ROM exercises. You ask her if she is experiencing muscle pain at this time and she nods “yes”. You tell P. R. that you will wait until she is pain-free to perform the exercises. Why?

It took P. R. 4 months to make a full recovery.
Respiratory Case Study 4.docx

Answer 1

Eternal nutrition minimizes adverse effects. it provides the most beneficial outcome, eternal nutrition is more physiologic, simpler, cheaper, and less complicated than TPN.
when there is intestinal function is absent due to an infection or inflammation EN would be contraindicated.medical diagnosis: severe burns, multiple trauma, intestinal fistula.
Measures to avoid the risk of aspiration include Raise the patient bed head with 30 -45degree recumbent position during the feeding. Avoid rapid bolus method for feeding. check the gastric residuals regularly. prefer high osmotic feeds.
preventing bacterial contamination of the tubing formula and tubing is important.  wash the hands regularly before and after handling the tube and feeding formula. use new feeding bags daily, use new syringes every day, the commercial formula should be used once opend within 12 hours period, store the formula in the area with correct temperature to avoid bacterial growth.
when the infusion rate is too rapid and the patient is intolerant to eternal nutrition it can be observed through patient vomiting, aspiration, abdominal pain and diarrhea.
Observation need to be recorded to avoid complications first observe the patient hydration status to prevent dehydration and malnutrition. next assess the patient's weight/BMI daily to avoid complications and adverse effects.
diarrhea occur when the patient is intolerant to EN, this it not natural consequences of EN administraiton, it needs immediate attention to avoid dehydraiton and complication.
3 factors that cause diarrhea are malabsorption syndrome, infection and concomitant drug therapy rather than eternal formula.