metabolism

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METABOLISM

Ma. Tosca Cybil A. Torres, RN, MAN

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Definition of Terms:• Metabolism- all biochemical reactions within the

body.• Basal Metabolic rate- energy requirement of an

awake person at rest– Energy needed at a person’s lowest level of cellular

function

• Nutrients- any ingested chemical that is used for growth, repair and maintenance of the body.

• Catabolism- breakdown of complex structures into simpler forms.

• Anabolism- process by which simpler molecules combine to build more complex structures.

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Gastrointestinal System

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Gastrointestinal TractUpper GIT

• consists of structures that aid in the ingestion and digestion of food

• includes the mouth, esophagus, stomach, duodenum

Hypothalamus – satiety center is responsible for notifying the body that it is

satisfied or has received sufficient foodLower GIT

• consists of the small and large intestines• digestion is completed in the small intestine , and

most nutrients are absorbed in this part of the GIT

• the large intestine serves primarily to absorb water and electrolytes and to eliminate the waste products of digestion through the feces

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Gastrointestinal TractMouth 1. Salivation

the “thought” of food initiates saliva production a.) serous secretions contain ptyalin for starch digestion – produced by parotid and submaxillary glands b.) mucous secretions - for lubrication of food – produced by the buccal, sublingual and submaxillary glands2. Mastication

chewing of food teeth - for initial breakdown of food to small particles it helps prevent excoriation of the lining of the tract and increase rate

of digestionMajor Structures in the Mouth

• teeth – to grind the food• salivary glands – moisten food and mucous membranes and begin

carbohydrate digestion• tongue – to push the food to the pharynx to initiate swallowing

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Gastrointestinal Tract Esophagus

is a hollow tube, the upper 1/3 is composed of skeletal muscles, the rest is smooth muscle

lined with mucous membrane – secretes mucoid substance for protection

the bolus of food arrives at the cardiac sphincter of the stomach w/in 5-10 secs. after ingestion

the lower esophageal sphincter (LES) prevents reflux of food in the stomach back into the lower esophagus

Swallowing (deglutition)3 phases:1.) tongue forces the bolus of food into the pharynx2.) the food moves into the upper esophagus3.) the food moves down into the stomach* Food is prevented from passing into the trachea by closing of the trachea (epiglottis) and the opening of the esophagus

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Gastrointestinal Tract

Stomach made up of 5 layers of smooth muscle

2 types of contractions:1.) tonus contractions – continuous contractions2.) rhythmic contractions – may be slow ( q2-3 mins.) or fast – responsible for the mixing of food and peristaltic movementVagus nerve – supplies the nervous stimulation for the stomach - has both symphathetic and parasymphatetic fibers

movement of food through the stomach and intestines is by peristalsis the alternate contraction and relaxation of the muscle fibers that propels the food in a wave-like motion

chyme – food in the stomach - is pumped through the pyloric sphincter into the duodenum

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Digestive Function of the Stomach:

Pepsin – needed for protein digestionHCL acid – aids in pre-digestion of food

the smell or taste of food &

presence of

protein foods

entering the

stomach

stimulate

gastrin

hormone

secretion

stimulates the flow of gastric juice

w/c has a high pepsin

and HCL

content

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IntestinesSmall Intestine

2.5 cm. (1 inch) wide and 6 meters (20 feet) long – fills most of the abdomen

3 parts :a.) duodenum – which connects to the stomach (10 inches)b.) jejunum – middle portion (8 feet long)c.) ileum – with connects to the large intestine (12 feet long)Large Intestine

6 cm. (2 ½ in.) wide and 1.5 meters (5 feet long) 3 parts :a.) cecum – which connects to the small intestinesb.) colon – 4 parts (ascending, transverse, descending, sigmoid colon)c.) rectum – 17-20 cm. (7-8 inches) long, anal canal

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ileocecal valve – prevents backward flow of fecal contents from the large intestine to the small intestine

vermiform appendix – has no function , near the ileocecal valve

anus – anal opening, is controlled by a smooth muscle internal sphincter and a striated muscle external sphincter

chyme is propelled toward the anus by peristalsis, also mixes the intestinal contents

in the colon, the feces is pushed forward by mass movements – stimulated by gastrocolic reflexes initiated when food enters the duodenum from the stomach

Defecation reflex when feces enter the rectum and cause distention of wall

of the rectum send impulses to the sacral segment of the spinal cord – then back to the colon, sigmoid and rectum initiate relaxation of the internal anal sphincter relaxation or contraction of external anal sphincter (voluntary control)

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Gastrointestinal TractSecretion and Digestion

major portion of digestion occurs in the small intestines by the action of pancreatic and intestinal secretions (enzymes) and bile

a.) Carbohydrate digestion start in the mouth Ptyalin – breakdown polysaccharides to disaccharides intestinal enzymes (maltase, lactase, sucrase)

breakdown disaccharides to monosaccharides (glucose, galactose fructose) b.) Protein digestion - start in the stomach pepsin – breakdown of proteins to polypeptides - small intestines trypsin – breakdown of polypeptides into peptides and amino acidsc.) Fat digestion - fats require emulsification into small droplets before it can be broken down into glycerol and fatty acidsBile – from liver; emulsify fats so that it could be broken downpancreatic lipase breakdown fats into glycerol and fatty acids

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Absorption the intestinal wall has many folds which are covered by

fingerlike projections called (villi) increase the absorptive area of the small intestines

in the center of the villi are capillaries, veins, small arteries for absorption of nutrients into the blood vessel system

90% of absorption occurs within the small intestines by active transport or diffusion

amino acids, monosaccharides, Na+, Ca++ are transported by active transport w/ the expenditure or use of energy

other nutrients, fatty acids and H2O – diffuse passively across the cell membrane

reabsorption of H2O, electrolytes and bile occurs mainly in the ascending colon

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Gastrointestinal TractGIT role in Fluid and Electrolytes Balance

GIT secretions contain electrolytes severe fluid and electrolyte imbalance may occur with excessive

losses of gastrointestinal fluids Ex. 1.) Na+ and K+ deficits : vomiting, diarrhea, gastric suctioning, intestinal fistula

2.) Ca++ & Mg++ deficits: malnutrition, malabsorption, intestinal fistula 3.) Metabolic alkalosis : loss of gastric acid by suctioning or persistent vomiting 4.) Metabolic acidosis : loss of bicarbonate-rich intestinal secretions by severe diarrhea or fistula

Other functions of the GIT the GIT supports bacterial growth and has a role in antibody

formation intestinal bacteria synthesize Vit. K required for production of

clotting factors II (Prothrombin), VII, IX,X

PHYSIOLOGY OF DIGESTION AND ABSORPTION

• Digestion: physical and chemical breakdown of food into absorptive substances.– Initiated in the mouth where food mixes

with saliva and starch is broken down.– Food then passes into the esophagus

where it is propelled into the stomach.– In the stomach, food is processed by

gastric secretions into a substance called chyme.

– In the small intestine, carbohydrates are hydrolyzed to monosaccharides, fats to glycerol, and fatty acids and proteins to amino acids to complete the digestive process.• When chyme enters the duodenum, mucus is

secreted to neutralize hydrochloric acid; in response to release of secretin, pacreas releases bicarbonate to neutralize acid chyme.

• Cholecystokinin and pancreozymin (CCK- PZ) are also produced by duodenal mucosa; stimulate contraction of the gall bladder along with relaxation of the sphincter of Oddi (to allow bile to flow from the common bile duct into the duodenum, and stimulate release of pancreatic enzymes.

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NUTRITION

• Nutrition is the sum of all interactions between an organism and the food it consumes.

6 MAJOR CLASSES OF NUTRIENTS

WATER 2.5 LMacronutrientCHO 125-175 g.LIPIDS 80-100 g.PROTEIN 44-60 g.MINERALS 0.05-3,300 mg.MicronutrientVITAMINS 0.002-60 mg.

WATER• Composes 60% - 70% of TBW• Lean people contain more water than obese people• *per ml/kg/day Behrman, Vaughan VC: Nelson’s Textbook of

Pediatrics, 1987

AGE FLUID REQ’T AGE FLUID REQ’T

3 DAYS10 days3 mos. 6 mos.9 mos.1 yr.

2 yrs.4 yrs.

80-100125-150140-160130-155125-145120-135115-125100-110

6 yrs.10 yrs.14 yrs.18 yrs.

19-50 yrs.

100-11090-10050-6040-50

50

Essential Nutrients CARBOHYDRATES (CHO) Types: • Sugars

– simplest of all CHOs– Water soluble– Produced naturally by plants and animals – May be monosaccharide or disaccharide

• Starches– Insoluble, nonsweet forms of CHO– Polysaccharide – Nearly all starches come form plants

• Fiber – Complex CHO from plants – Cannot be digested by humans but supplies roughage or bulk to

the diet MTCAT '09

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Digestion (CHO)

• Desired end product of CHO are monosaccharides (Glucose, fructose, galactose)

Major enzymes: • Ptyalin (salivary amylase) • Pancreatic amylase

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Metabolism (CHO)

• Storage and conversion – Stored either as glycogen or fat

Glycogen • Large polymer of glucose • Process of glycogen formation----

GLYCOGENESIS• Stored mostly in the liver and skeletal muscles• Glucose that cannot be stored as glycogen are

stored as fat

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Glycogenolysis• Breakdown of glycogen to reform glucose for

use of cells • Activated by GLUCAGON and EPINEPHRINE

– When blood glucose concentration falls alpha cells (pancreas) secrete glucagon stimulates glycogenolysis mainly in the liverliver delivers glucose to the bloodstream elevate blood glucose level

– SNS stimulated adrenal medulla releases epinephrine stimulates glycogenolysis in both the liver and muscle cells release energy needed during sympathetic stimulation

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• Gluconeogenesis –Process of forming of glucose from

protein (amino acids) and fat reserves–Occurs in the liver –Only up to 60% of CHON can be

coverted into glucose

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Essential Nutrients • PROTEIN (CHON)

– Organic substances composed of amino acids – Amino acids are the most important components of protein.

Essential for synthesis of body tissue in growth, maintenance and repair.

– It is responsible for muscle contraction and motility of cilia and flagella.

– Yields 4 kcal/g– RDA is 44 to 60 g depending on age and sex.– Multiply your wt. in lbs x 0.37 = e RDA

Category:• Essential amino acids

– Those that cannot be manufactured in the body and must be supplied as part of the diet

• Non essential amino acids– Can be manufactured in the body

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Digestion (CHON)

• start in the stomach pepsin – breakdown of proteins to polypeptides

• small intestines trypsin – breakdown of polypeptides into peptides and amino acids

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Metabolism (CHON)

• Storage –Absorbed by active transport through

the small intestine into the portal blood circulation

–CHON is “stored” as body tissue–Body cannot actually store CHON for

future use.

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Essential Nutrients

• LIPIDS – Organic substances that are greasy and

insoluble in water but soluble in alcohol or ether.

– Fats are lipids that are solid in room temperature

– Oil are lipids that are liquid in room temperature

– Fatty acids basic structural unit of most lipids

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Digestion (LIPIDS)• Starts in the stomach digested mostly

in the small intestine by bile, pancreatic lipase and enteric lipase End product are glycerol, fatty acids, and cholesterol reassembled in the intestinal cells into triglycerides and cholesterol esters (cholesterol w/ fatty acids) converted by the small intestine and liver to LIPOPROTEINS for transportation

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Lipoproteins

Lipoproteins- made up of various lipids and a protein

Classification – High-density lipoproteins (HDL) contains the highest

concentrations of CHON (50%)– Low-density lipoprotein (LDL) contains very high

concentration of cholesterol – Very-low-density lipoprotein (VLDL)contains little

protein but high concentrations of triglycerides and moderate concentrations of phospholipids and cholesterol

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Storage (LIPIDS)

Store in 2 major tissues:

• Adipose tissue (fat depot) – Stores triglycerides until needed for energy– Insulator

• Liver

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MICRONUTRIENTS

Vitamin• An organic compound that cannot be

manufactured by the body and is needed in small quantities to catalyze metabolic processes

• Abundant in fresh foods eaten as soon as possible after harvest

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Vitamin classification:

Water-soluble vitamins– Cannot be stored in the body body needs

daily supplementation – Vitamin C, Vitamin B-complex

Fat-soluble vitamins – Can be stored in the body vit E and K with

limitation – Daily supplementation is not absolutely

necessary – Vitamin A, D, E, K

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Minerals

• Inorganic elements essential to the body because of their role as catalysts in biochemical reactions.

CLASSIFICATION• Macrominerals. When the daily

requirement is 100 mg or more• Microminerals. When the daily

requirement is less than 100 mg.

FOUNDATIONS OF AN ADEQUATE DIET

• Food Guide Pyramid - 1992• Recommended Daily Allowance – 1943 –

level of intake of essential nutrients considered to be adequate to meet the nutritional needs of healthy people

• Other Dietary Guidelines (1990)– Eat a variety of food– Choose a diet low in fat, saturated fat and

cholesterol.– Choose a diet with plenty of vegetables,

fruits and grain products.– Use sugar in moderation.– Use salt in moderation.– If you drink, do so in moderation.

The Food Pyramid

GRAINSVEGETABLE

SFRUITS OILS MILK

MEAT & BEANS

DEVELOPMENTAL VARIABLES IN NUTRITION

• Infant. Needs a high amount of fluid; High energy requirementBreast-fed Infants. Breast milk as the major source of nutrients for the first 4 to 6 months.(80-100ml/kg of body weight) Vit. C supplement can be given at 1 to 2

mos. Iron can be given after 4 mos.

• Toddlers and Preschoolers Growth rate slows during toddler years

(1 to 3) Needs fewer calories but an increase

amount of protein in relation to body weight.

Should also receive four servings of fruits and veggies.

School age children Grow at slower and steadier rate, with a gradual decline in energy requirements per unit of body weight.

Adolescence– Increase caloric need, as well as the

protein and calcium need for bone growth

– Nutritional deficiencies occur. – fad diets.

Young and Middle adult– Needs nutrient for energy,

maintenance and repair.– Pregnancy. Total weight gain of 10-15

kg. (22 to 35 lbs) is recommended• Calcium Intake of 1200 mg/day esp. in

the 3rd trimester• Iron 30 mg/day

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FACTORS INFLUENCING DIETARY PATTERNS

• Health Status“ a good appetite is a sign of health.”

• Culture and Religion• Socioeconomic Status• Personal Preference• Psychological Factor• Alcohol and drugs• Misinformation and food

fads.

VARIABLES AFFECTING AN INDIVIDUAL’S CALORIE NEED

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Higher BMR Lower BMR

Assessing Nutritional Status

“ABCD Approach”Anthropometric

measurement

Biochemical Data

Clinical signs

Dietary History

ANTHROPOMETRY• System of measurement of the size and make

up of the body and specific body parts.• INCLUDE:• Weight*• Height• BMI = wt. in kg/ (ht in meter) 2

– 20-25% Normal– 27.5-30% Mild Obesity– 30-40% Moderate– Above 40% Severe

• Wrist circumference• Mid upper arm circumference (MAC)• Triceps skin fold (TSF)

• Height and weight should be obtained on hospital admission.

• Weigh daily.• Wrist measurement is used to

estimate the client’s body frame.– Height in cm divided by wrist

circumference= frame size– N value= >10.4 to 10.9cm

(small), 10.4 – 9.6 (Medium),< 9.6 (large)

• MAC determines muscle wasting.– Measured at the mid

point of the arm.– N values = 28.3 men,

28.5 women• Skinfold measurement

determine fat content of subcutaneous tissue.– N values = 12.5 cm

men, 18 cm women– Other areas measured

biceps, scapula and abdominal muscles

Biochemical Data• Hgb & Hct indices• Serum albumin• Transferrin (blood

protein that binds with iron)

• Total lymphocyte count

• Nitrogen balance• Creatinine

excretion

Clinical Signs Indicative of Nutritional Status• Hair- dull, brittle, depigmented,

easily plucked• Face- skin dark over cheeks and

under eyes, skin flaky, face swollen• Eyes- Eye membranes pale, dry

(xeropthalmia), Bitot’s spots, increased vascularity, cornea, soft (kerotomalcia)

• Lips- swollen and puffy (cheilosis), angular lesions at corners of mouth (angular fissures)

• Tongue- smooth appearance, swollen, beefy red, sores, atrophic papillae

Clinical Signs

• Teeth- Cavities, mottled appearance (fluorosis), malpositioned

• Gums- spongy, bleed easily, marginal redness, recession

• Glands- thyroid enlargement (simple goiter)• Skin- rough, dry, flaky, swollen, pale,

pigmented, lack of fat under skin• Nails- spoon shaped, ridged• Skeleton- poor posture, beading of ribs,

bowed legs or knock legs• Muscles- flaccid, poor tone, wasted,

underdeveloped• Extremities- weak and tender, presence of

edema• Abdomen- swollen• Nervous system- decrease in or loss of ankle

and knee reflexes

Clinical signs

It considers the quantity and quality of food intake and also frequency of consumption of certain food items in order to

determine the current or customary intake of nutrients.

Dietary History

Food Record Used most often in nutritional status studies. The client is asked to keep a record of food

actually consumed over a period of time, varying from 3 to 7 days.

It appears to be fairly accurate.

24- hour Recall Recall of food intake over a 24- hour period. The subject is asked to recall all food eaten

during the previous day and to estimate the quantities of food consumed.

Information obtained by this method is not always representative of usual food intake.

Methods

CLIENTS AT RISK FOR NUTRITIONAL PROBLEMS

• Obesity – condition in which there is 20% increase above ideal body weight.

• Anorexia nervosa – self-imposed starvation

• Bulimia – binge-purge syndrome• Post op clients• Immobilized client• Cancer and radiotherapy

Food and Fluid Intake regulating Mechanism

Thirst – triggered by loss of fluid of more than 2 %

Hunger – triggered by low blood glucose level

Appetite – sight, smell, and thought of food

Satiety – triggered by gastric distention

Regulation of Food Intake• Hypothalamus – regulation of feeding

and satiety– Ventromedial nucleus – satiety center

(stimulation results in cessation of appetite)– Ventrolateral area – initiate feeding

behavior and has termed feeder center• Blood glucose concentration – is

thought to be a major regulator of activities of the center.

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Diagnosing

• Altered nutrition: more than body requirements• Altered nutrition: less than body requirements• Activity intolerance• Constipation • Diarrhea• Knowledge deficit• Self-esteem disturbance • Potential for impaired skin integrity

IMPLEMENTATION• Stimulating Appetite (depending on the medical

condition)– Serve food in pleasant and attractive manner– Mouth care– Position comfortably– Promote comfort

• Relieve pain• Adequate ventilation and humidity• Remove unsightly articles• Check very tight or very loose clothing

– Remember that color affects appetite to eat.– Environment – curtain the unit of patients on NPO– Diet Therapist– Special Diets– Hospital Diets

• Diet therapy in disease management

Modification Medical indication

Rationale Foods to avoid

CLEAR LIQUIDEliminates all food except clear liquids

LIQUIDIncludes liquid at room temperature, including milk products

Presurgical period

Post surgical period

Empties Gastrointestinal tract to prevent aspiration and possibly clean surgical site (no residue);

prevents dehydration

Increase calories and

nutrients gradually, as

tolerated



SOFTEases mechanical digestion

LOW RESIDUEReduces fiber and cellulose

Problems with chewing,

swallowing poor digestive

function; ulcerative

colitis; Crohn’s disease

Diverticulitis, ulcerative,

Colitis, Crohn’s disease

Provides step between liquid

with regular diets; provides

more diet

Reduces Physical

irritation to mucosa

Seeds, skin fruits, fried fruits, whole grains, raw

fruits, vegetables,

highly seasoned foods

Raw food and vegetables

(except bananas), raw

plant fiber, whole grains, milk products

(limited to 2cups/day)



HIGH FIBERIs normal diet with increased fiber from raw

fruits and vegetables

FAT CONTROLLEDReduces total

fat and replaces saturated with

monounsaturates and

polyunsaturates; restricts

cholesterol

Diverticulosis

Atherosclerosis, elevated cholesterol triglyceride

level, coronary

heat disease, obesity

Promotes normal vesion of indigestible wastes from

colon

Reverses and slows down conditions

None.(use General

guidelines

Saturated (animal) fats,

gravies sauces, egg

yolks, high-fat meats, whole

milk



SODIUM RESTRICTED

Restricts sodium

intake: mild (2-3g),

moderate (1000mg),

strict (500), severe (250

mg)

LIBERAL BLAND

Eliminates food that are chemical or mechanical

irritants

HPN, MI, CHF

Gastritis, gastrointestin

al ulcers

Reduces sodium levels

to aid in reducing total fluid volume ,

thereby reducing

blood pressure,

work load on heart, and

excess fluid

Reduces gastrointestinal irritation;

improves food tolerance

Highly salted foods, added salt at meal

table (depends on

level of restriction

Fried foods, strong spices,

caffeine, alcohol,

decaffeinated coffee

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Alternative Feeding:

1.Enteral hyperalimentation- delivery of nutrients directly to the GI tract.

a. Short- term- esophagostomy; nasogastric tube

b. Long- term- gastrostomy; jejunostomy

Indications of NGT:

a)Gavage- to deliver nutrients and medication; for feeding purposes

b)Lavage- to irrigate the stomach

c)Decompression- to remove stomach contents or air

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SKILLS: NGT InsertionPURPOSES OF NGT INSERTION:

• To provide feeding • (gastric gavage)• To irrigate stomach • ( gastric lavage)• For decompression (drainage of gastric

content)• To administer medication.

INSERTION

• Inform the patient and explain the procedure.

• Place in high- Fowler’s• Measure length of NGT to be inserted (NEX

technique) = 50 cm.• Lubricate tube with water soluble lubricant.

To reduce friction. Do not use oil.• Hyperextend the neck, gently advance the

tube toward the nasopharynx.• Tilt the patient’s head forward once the tube

reaches the oropharynx, and ask to swallow as the tube is advanced.

• Secure the NGT by taping it to the bridge of the client’s nose, after checking the position of the tube placement.

Administering Tube Feeding Assist the client to a semi-Fowler’s position in bed

or sitting position in a chair, or slightly elevated right side-lying position.

Assess tube placement and patency.• Introduce 5-20ml of air into the NGT and

auscultate at the epigastric area, gurgling of sound is heard.

• Aspirate gastric content, which is yellowish or greenish in color.

• Immense tip of tube in water, no bubbles should be produced.

• Measure the pH of the aspirated fluid which should be acidic.

• Ask the client to speak or hum• Observe the client for coughing or choking.

The most effective method of checking the NGT is radiograph verification then, checking pH of aspirated gastric content.

Assess residual feeding contents. to assess absorption of the last feeding, if 50ml or more, verify if the feeding will be given.

Introduce feeding slowly. To prevent flatulence, crampy pain and or reflex vomiting.

Height of feeding is 12 inches above the tube’s point of insertion into the client. This allows slow introduction of feeding.

Instill 60 ml of water into the NGT after feeding. To cleanse the lumen of the tube.

Clamp the NGT before all of the water is instilled. To prevent entry of air into the stomach.

Ask client to remain in Fowler’s position or in slightly elevated right lateral position for at least 30 min. To prevent potential aspiration of feeding.

Do after care of equipment. Make relevant documentation.

GastrostomyA gastrostomy is a surgical procedure

in which an opening is created into the stomach for the purpose of

administering foods and fluids

via a feeding tube.

Meeting Nutritional Needs The first fluid nourishment is administered soon after

surgery and usually consists of tap water and 10% dextrose. At first, only 30 to 60 mL (1 to 2 oz) is given at one time, but the amount administered is increased gradually. By the second day, 180 to 240 mL (6 to 8 oz) may be given at one time, provided it is tolerated and no leakage of fluid occurs around the tube. Water and enteral feeding can be infused after 24 hours for a permanent gastrostomy.

Blen foods can be added gradually to clear liquids until a full diet is achieved. Powdered feedings that are easily liquefied are commercially available.

NURSING CARE OF CLIENTS WITH GASTROSTOMY

• Providing Tube Care and Preventing Infection

• Providing Skin Care• Enhancing Body

Image• Monitoring and

Managing Potential Complications

Teaching Patients Self-Care• Demonstration of the tube feeding begins by showing the

patient how to check for residual gastric contents before the feeding.

• All feedings are given at room temperature or near body temperature.

• For a bolus feeding, the nurse shows the patient how to introduce the liquid into the catheter by using a funnel or the barrel of a syringe. The receptacle is tilted to allow air to escape while the liquid is being instilled initially. As the funnel or syringe fills with liquid, the feeding is allowed to flow into the stomach by gravity by holding the barrel or syringe perpendicular to the abdomen. Raising or lowering the receptacle to no higher than 45 cm (18 in) above the abdominal wall regulates the rate of flow.

• A bolus feeding of 300 to 500 mL usually is given for each meal and requires 10 to 15 minutes to complete. The amount is often determined by the patient's reaction. If the patient feels full, it may be desirable to give smaller amounts more frequently.

• The patient and caregiver must understand that keeping the head of the bed elevated a minimum of 45 degrees for at least 1 hour after feeding facilitates digestion and decreases the risk of aspiration. Any obstruction requires that the feeding be stopped and the physician notified.

Teaching Patients Self-Care

View Figure Bolus gastrostomy feeding by gravity. (A) Feeding is

instilled at an angle so that air

does not enter the stomach. (B)

Syringe is raised perpendicular to the abdomen so that feeding can enter by gravity.

• The patient or caregiver is instructed to flush the tube with 30 to 50 mL of water after each bolus or medication administration and to also flush the tube daily to keep it patent.

• The patient and caregiver are made aware that the tube is marked at skin level to provide the patient with a baseline for later comparison. They are advised to monitor the tube's length and to notify the physician or home care nurse if the segment of the tube outside the body becomes shorter or longer.

Teaching Patients Self-Care

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2. Hyperalimentation (total parenteral nutrition)- method of giving highly concentrated solutions intravenously to maintain a patient’s nutritional balance when oral or enteral nutrition is not possible

Nursing Managements:

• Filter is used in the IV tubing to trap bacteria

• Solution and administration equipment should be changed every 24 hours

• Dressing changes every 48-72 hrs with antibiotic ointment to catheter insertion

• Medication is never administered in a TPN line

• Observe for complications

• Infection

• Venous thrombosis

• Hyperglycemia

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Evaluation

metabolism

Technology

digestion of food

bolus of food

food moves

mixing of food

reflux of food

lubrication of food

initial breakdown of

motion chyme food