Understanding Enteral Nutrition Fundamentals

Hey guys, Woodruff here. So now let's go over enteral nutrition. So enteral nutrition is one of the treatments we talked about for malnutrition. But just so you know, enteral nutrition is a general like, well, I'm going to get to that point. It's a general treatment that can be used for someone who's malnourished. It can be used for someone who's perfectly nourished, but maybe they can't eat normally right now. So we need to supplement their nutrition. Sometimes we give people mostly enteral nutrition, but they can still eat regular food. Or sometimes people are eating regular food, but we need to supplement that because it's not enough. So we give them enteral nutrition. And what it pretty much is, this video is going to be about enteral nutrition. I'll have another one about parenteral nutrition. But enteral nutrition is entering into your body through a tube. So which is why we always so call this tube feeding. And what is happening is pretty much there's... tube feeding going in through a tube and it gets delivered directly into your GI tract. So you may be wondering like, okay, well, why would someone need this? Why can't we just let them eat? Well, sometimes people can eat, but they can't eat enough. So someone like with anorexia or that has burns or something else, they maybe need extra nutrition. So that's sometimes why we do tube feeding because they have like, we're not able to meet their nutritional needs just alone with regular food. Sometimes they have... mental status, other issues like patients that have had strokes, or maybe had a brain injury, other stuff, they may have lost the inability to swallow safely, or they may not be awake enough to eat. Also, people that are critically ill that are like, they have, they're intubated, they have a breathing tube, they may also need tube feeding while they're intubated, because they don't have a way to eat. Otherwise, even though people do try to stick those hamburgers down those breathing tubes, don't do it. And then you also have to consider people that maybe have something going on with their head, face, and neck. So like oral facial cancer, sometimes that can be an indicator for tube feeding or anyone who can't swallow safely. So think of people who can't swallow safely, maybe they have something going on, maybe there's some sort of obstruction, blockage, permanent or temporary airway going on, and we need to bypass that to get food into their stomach. So patients... in order to receive tube feeding, the one qualifier there, aside from, of course, the need to have it, because we don't just stick these tubes down for fun, is that we need them to have a functioning GI tract. And what I mean by that is they need to have the presence of bowel sounds. Like, you know, I'm not going to start putting food into a patient that possibly has like an ileus or their bowel, a bowel obstruction, their bowels aren't moving, because it could lead to very, very serious things like, we're going to talk about it soon, but the three P's, pain, perforation, peritonitis. So We definitely don't want to be getting into that. So assessing for bowel sounds before feeding is super important. Tube feeding can be given via bolus, which what that means is that, you know, I'm coming by, we have cans, I'll get a syringe and I will, with gravity, pour in the cans over a short period of time in order to give them kind of like a bolus. So think of it like a bolus of a medication, like when you're given like an IV push, you're giving it one time, you know, like over a short period of time. And then they might, obviously with a bowl-less feed, they might get it. It would, it would more mimic what we do when we eat, like you and I eat, where like we have three meals throughout the day. So it's the same kind of thing. It will say to give so many cans throughout the day. Continuous feeding would be when someone gets it via pump, when this is, you know, this is what you're going to see more commonly done, especially with acutely ill people, because sometimes they need to have more nutrient needs, stuff like that. Um, there's... there's mixed theories about it. Some people say the bolus feeds are better because it more mimics what your body is used to, you know, your body's not used to continually having nutrition going into your stomach all the time. But there's pros and cons having the continuous does help stuff, it is considered like a PPI prophylaxis to some physicians. But then on the downside, you know, elevated blood sugars, overloading the stomach, you know, diarrhea, there's other issues and stuff that could happen. So I'll tell you, most of the time you're going to see it given continuous, but there are some times that it's given bolus. There's also, of course, if I'm going to give food via a tube, I need a tube. So the tubes you're going to see given, there is an NG tube, which is a nasogastric tube. You can see it here in this picture, goes in through the nose, right or left, doesn't matter, whichever one, it will go down. There's an OG, which is an orogastric. And you're only going to see this one. An NG is probably going to be the most common one you see. The OG is going to be given only to patients that... have like breathing tube, stuff like that. Or for some reason they can't go in the nose, but you're not going to see a patient up and talking with like a feeding tube out their mouth. Usually it's going to only be if they have a breathing tube. They'll have that one. Then there's a Dobhoff. And this one's a specifically, it's a small bore tube. It usually has a wire in it when you place it and it goes in deeper. It can actually go all the way. And I mean, NG tube can, well, now I've never heard that before. And I'm going to take that back. So Dobhoffs can go in farther. They can actually go. into the duodenum, which is past the stomach. So we call it a post-pyloric tube. It's also, like I said, it's thinner, a more flexible tube and stuff like that can be a little bit more comfortable. So most of the time you're going to see an NG tube or a Dobhoff. And there's not going to be a test question where we're like, which of these tubes is most appropriate for a patient? Because that's not your decision. But I'm just kind of explaining what these tubes might look like and why. And I'll talk more about the Dobhoff and stuff later. And then there's also a PEG tube. And this is one that's, you know, it's, it's, you're going to see like the tube come out of the stomach. So this is a more of a long-term tube. And so it's going to come out straight from the stomach and it's called, it's different than like a G-tube because we put it in through endoscopy. Whereas the G-tube is more of a surgical tube that go in and insert surgically. And then a J-tube is a jejunostomy tube. I can't believe I said that right the first time. I'm so proud of myself. So a jejunostomy tube, this goes in your jejunum, which is in your intestine. So I was talking about with the Dobhoff, we can bypass the stomach. You may wonder, like, why would we want to go all the way in the jejunum or into the duodenum? And the reason for that is that some patients are really high risk for aspiration. And so we're trying to bypass that. Or sometimes people have these tubes, if they have, when we talk about pancreatitis, we talk about these. because we don't want them to secrete any more pancreatic enzymes. So if we can bypass where they're going to secrete pancreatic enzymes, we want to do this. But long-term people that are really high risk for aspiration, these tubes are preferred because that way we don't have to worry about stuff backing up as easily. Let's see if I can move forward. Come on. All right, there you go. So what am I going to do to maintain the tube and prevent aspiration? Because aspiration is a very big risk. So one thing you'll want to know about these tubes, is that there's high risk for them getting pulled out, sometimes inadvertently, inadvertently, on purpose or not is what I'm saying. And then there's high risk for aspiration because I'm giving them kind of continuous feed, sometimes overfilling their stomach. So we always want to assess the tube for patency and correct placement before we give anything. So what that looks like is when the tubes first put in, like, you know, I put one in the other day in a patient who had one, but I had to replace it. So I took out their old one and I put the new one in. But before I used it for anything, I went and got what's called a KUB or kidneys, ureter, bladder x-ray. It's an abdominal x-ray. I verified that it was in the right place with that image and not me, but the doctor verified it was in the right place and said it was okay for use. And then as a nurse on a daily or regular basis, what I'm doing then is I'm looking at the tube marking. So you can kind of see it here. Um, here there's these little markings here on this tube, on this picture. They'll usually have numbers by them too. And then with that, it's going to tell me if it's in the right place. So the nurse will give me a report and say, hey, your NG tube's at 70 in the left nare. And so that I'm just looking that it's in the right place. Um, and then paint and C2, always want to flush the tube before you put anything else down it. Make sure that it's flushing. Okay. Just like you would an IV. Um, we maintain the placement with tape or a bridle. And, you know, there's a lot of pressure related skin injuries. They've created some different devices that allow it to hang off of. And that looks kind of scary when I put my finger like this on my nose, but that allow it to hang off of the nose without putting too much pressure on the skin. What a bridle is, is what is in this picture and what that actually and like, I mean, where I work, nurses can be trained to do this. But most facilities, I think physicians do it or especially trained team. But what it is, is what do you call it? There's a. a string, you can kind of see it here, this white string, it actually wraps around the septum of the nose. I remembered it this time. I think when I did a lecture last semester, I couldn't remember the name for septum, but I finally remembered it this time. Maybe it was early this semester. I think early this semester, I couldn't think septum. So I've redeemed myself finally in life. I can, I can die a happy person because I'm not a complete fool. All right. So the septum of the nose, it wraps around that. So if a patient tugs on it, all it's going to do is give them the worst headache of their life. And it can't get pulled out. So it's definitely preferred, especially for patients that really are tugging at that thing, because eventually they're not going to want to tug at it, trust me, because I didn't believe it either. I was like, they're going to just keep pulling. They eventually stop because it hurts. Anyway, so it's wrapped around the septum and you do it with a magnet. It's actually pretty cool to see, but you do with the magnet to get the two pieces of the two pieces tied together. So it's kind of too hard to explain in a video, but you can look up like bridling and maybe search NG tube bridling because I don't know, like there's so many weird things out there that students have told me, like are dirty things that I didn't know were dirty things. So maybe don't just search bridling because that sounds weird. Maybe just search NG tube bridling and then see what you find. And hopefully, knock on wood, you won't regret Googling that. But anyway, so taper, bridle, or one of those special securement devices. Then also assess for bowel sounds before feeding. Like I said, you have to have patent bowels in order to do this. Appropriate client positioning is going to be 30 to 45 degrees if they're continuous feeding, like through a pump. And it's very controversial, or you'll see some nurses that put patients head down to turn them real quick, and they're like... They're going to be fine for the 10 seconds I put their head down. I usually pause my tube feeding when I put my head down, a patient's head down, just because you never know. But, you know, it may be a force of habit. But, you know, usually I try to pause it if we're, you know, if we're putting them down just to kind of prevent any aspiration that short period of time. But yeah, then if that's for if they're continuous feeding and you really want to keep them at that all the time. So some patients, they want to lie their head down. You just have to tell them, hey, it's not really safe while you're getting this feeding. For someone who's getting the bolus feeding, you just need to keep them upright for 30 to 60 minutes after. There's different policies about gastric residuals. So what I'm talking about here is that patients can, you know, the stomach wasn't meant to continuously have food in it. It takes sometimes a while to digest. You have to think about patients that are receiving this, they're going to be bed bound. They might not be moving or getting around as much. And as a result of that, they can have gastric residual or like they can have more. food contents or that tube feeding contents in their stomach. And so we caught as a result of this, they can end up being high risk for aspiration vomiting, or pretty much just think like the stomach's getting overfilled. So think of like a bottle of water, we keep pouring in more water, eventually, it's going to overflow, especially if there's not, you know, if we're not emptying well, and a lot of people that again, are immobile, sick, they may have decreased gastric motility. So we can depending on our hospital policy. Sometimes we check it like, so what I'll do at the beginning of my shift, if I have a regular NG tube, we don't do these usually with doll puffs because they're too thin. And by the way, this is a doll puff, this yellow tube here that's super skinny, where regular NG is usually clear. But with a regular NG, I'll pull back on it and see how much I can get. Now I've gotten upwards of 500 out of someone's stomach. Usually, I mean, we like there to be nothing, but I want to say you're I don't know if your new book says a certain amount, but usually we like it like less than a hundred or something like that. Maybe a hundred or 200. Let's say it's a hundred or maybe even less than that. But what do you call it? We usually don't like that much. So if I have a couple hundred in there, sometimes I'll call the doctor and say, Hey, you know, kind of just warns me that like, maybe, you know, and I'm not going to go and play doctor and say, I'm going to hold this feed or whatever, but I'm going to just call the doctor. What do you want to do? Because sometimes they'll tell me, Hey, don't give back whatever I took out. Um, but the one thing to keep in mind there is if I took out like, let's say 500 cc's of a patient, that's a lot of volume I'm taking out if I'm not putting it back. Cause I know you're probably going to find this disgusting, but if you didn't know this, what I, what I was talking about is, is like, I'll get to the NG tube. I'll literally pull back and see what I can get out of their stomach. And, um, sometimes it's, uh, like I said, it's multiple hundreds, but after I'm done with it, then I use, I put it right back. So then I suck it back up and then, um, like actually give them back. um, this food or, um, a lot of times it's their gastric acid too. So this is the other thing. And when we talk about, um, we talked about the beginning of the semester, we talked about acid base imbalances. We mentioned the fact that sometimes if we're sucking out too much of someone's gastric acid, it can lead them to be at risk for, um, you know, certain types like a metabolic alkalosis. I want to say yes. Yeah. Alkalosis. Yeah. Cause we're taking out their acid. Um, am I saying that right? Yes. Yeah. Metabolic alkalosis. All right. I was having a moment of doubt. And so just be extra cautious. Like if you are somewhat like, you know, I remember when I first started, like I was sitting there and I would take out a couple hundred and the doctor's like, it's fine. Just give it back. And I was like, oh, but this is so much like I was so worried about it. But remember, you're not just pulling out food from their stomach. You're also pulling out acid. And so if I take away their acid, they could have acid base imbalances. I'm taking out some of their volume. It can lead to some serious issues. So you're not just taking out one thing there. So you definitely usually want to give it back. but just check with your physician. And again, it's all about hospital policy. We're not going to give you a question about this because it's not a universal thing. It varies by hospital. Then for general maintenance, we're also going to flush the tube usually about every four hours or so. And if it's continuous, it's usually going to be programmed in the pump. And then if they get a bolus feeding, you'll do it like before and after just to keep the patency of the tube because that stuff is thick. So you want to make sure to flush it well. This kind of shows like if the NG tube is not placed. Well, this is where it should be placed here on the left. But if it's not, it can go in the beautiful lungs. You definitely don't want to be feeding in there, which is why you always need to check placement first. All right, so let's look at some questions here. So what would you do to maintain the patency of the tube while maintaining? So these are some like critical thinking questions. So what would you do to maintain patency of the tube while maintaining a fluid restriction? So think like a heart failure patient. So to maintain patency of the tube, we said we needed to flush it, but how can I flush it and give that? Do I, like most patients that are heart failure, they're on a fluid restriction. So how do I keep the tube patent while also not overloading the patient is what this question is asking. So it's all about a balance. The doctor will decide how much free water is given. So but just keep in mind that, like, you know, there's sometimes that I mean, the doctor didn't necessarily order to order you to do it. But let's say you have meds to give through that tube. Hold on a sec. I'll be done in a few minutes. I'm sorry. My son's waiting for some time together. Anyway, so the doctor, you know, not necessarily ordered this, but anytime you give meds down that tube. you have to flush before and after. So sometimes they end up getting an in it, like, you know, an unintentional flush. So, but I always try to consider, so if I have a patient who's really fluid overloaded, I try to put the minimal amount of fluid to like mix the meds and the minimal, minimal amount before and after to keep that tube patent. So just trying to keep it simple with those kinds of patients where they still need the tube flushed, but maybe not as frequently. And then, you know, just kind of being cautious because sometimes like I don't even need to regularly flush the tube because I'm regularly giving meds. through the tubes, they're getting flushes automatically. But that's like not perfect nursing school world, you know, in perfect nursing school world, we want to flush it every four hours. So what would you do if you were unable to flush your NG tube? So this is something you might find kind of cool, but they actually have this. If you like, there's a couple different things that you can do. If I'm trying to flush and maybe like, cause sometimes people don't crush pills well enough and it clogs your tube. Or sometimes people have very thick secretions and maybe some of their secretions block the tube. What you can do. Some people just pour soda down it and there's something about the stuff in soda, maybe it's the carbonation or something, it breaks it down. But there's actually like a, these pancreatic enzymes, I think is what we put down that can actually help the tube to flush. And you'd be surprised, it's kind of like when people's, their PICC lines clot off and we put the quick clot in, we let it sit for a little bit and then see if we can flush the tube. But yeah, so sometimes it's kind of a, it's a double edged sword. Because you're trying to push down this pancreatic enzymes into the tube to get it to, you know, to clear out. But you can't even get that medicine in the tube enough to get it in. But you do the best that you can. But you'd be surprised sometimes how it can get broken down. So, but definitely if you're unable to flush it. Yes, sir. Dylan, I'll be done soon. So. Don't mind this. I think this is what makes these videos so realistic because I promise that my family's not paid actors. This is really my life. And I'm usually interrupted a lot more than this. But anyway, so but the unable to flush the tube, I mean, hopefully, always first make sure it's unclamped all the way. And you know, your stopcock's in the right place. But then you know, you definitely want to try. You never want to force it. or try to make it more difficult. It's always like heartbreaking when your tube, because sometimes it kinks or something else and you try to move it a little bit, still doesn't work. But then at the end of the day, if you can't flush it, you can't use it. You're not gonna be able to get anything down in any way. So sometimes you have to take it out and put it back in if the other stuff does not work. There are times, like I mentioned too, sometimes it's not about there's something in the tube, but sometimes the tube gets kinked, especially those thinner Dobhoff tubes. So sometimes I've had to like move it a little bit and then it will start to work. Um, always re-verify with a new image. So what would you do if you assess your NG tube and it's too far in or too far out? So in cases like that, if my NG tube is too far in, um, what do you call it? I definitely want to make sure it's still in the right place. And cause sometimes what can happen is you might think, Ooh, I want it super in, but there's times it gets like circled around in the patient's stomach. It can actually clamp off, um, or not be working as well. We don't want it like suit, like the whole thing in the stomach. Like, you know, we just want. the tip in the stomach. And like, usually we want it farther in the stomach, but not like, not at the, just at the top, but we don't need to be jamming this thing deep inside of them. So usually if it's too far in, we'll just pull it back a little bit. And usually the radiologist will even say that in the report, they're like, Hey, pull it back this far. Or the doctor may tell you to do that. If it's too far out, then we can try to push it back in just depending on the situation. I usually check with the doctor. Hey, do we still want this in? And cause again, people pull on these things. Sometimes on purpose, sometimes not. If it's too far out, then I might, again, I might push it forward and advance it. And then I'll get another image to make sure that it's still in place. If your client pulled out their NG tube, again, the first thing I do is I make sure, like, do they still need this tube in? Like, is it still necessary? Is this a tube that we're going to be using for the future that we need? Because sometimes we keep tubes in patients sometimes, you know, and no one ever asked and stops and says like, hey, do we still need this as an indicator? Is there another option? Especially if you have a patient who's like determined and set on doing it. Because I had a patient once that was like, she had a wrist and she was like a 90 pound little woman. Like, I don't know how she had so much strength, but I'll tell you, she was feisty. And so, but she had mittens on and wrist restraints. And that's what we had to do to keep her NG tube in to feed her. And then like they were planning on bringing her home. So I'm like, well, how's she going to go home? Like, you know, like what are they going to hold her down with at home? So yeah, it's hard stuff. So you always want to ask like, is this necessary? We still need this. Is there an alternative? And if there's not, then you just get an order to put a new one in and they get a new image for that. And if I'm like the other day when I had to take one out and put a new one in, I always try to do it in the other nose if I can. Or in there, excuse me. Not the other nose because you only have one nose. Hopefully, other nair. What would you do if your sudden client receiving tube feeding suddenly develops coarse crackles bilaterally? What could this indicate? This could indicate aspiration. So if someone that I was taking care of started to get coarse crackles, and I've had this happen before, we usually talk to the doctor, want to get an x-ray. Because I mean, sometimes it can be other processes that lead to that, depending on why the patient's there. But we definitely want to be looking for aspiration. I want to be checking their head of. bed, make sure that it's elevated enough and make sure that the tube's in the right place. Cause I've had it happen where the tube comes out a little bit. And so it's just the location of it. It puts them at super high risk cause it's not actually in the stomach, it's in the esophagus. So yeah. So checking placement of everything, positioning in the bed, x-ray to see what's going on and then take it from there. They may need antibiotics if it's aspiration pneumonia. The doctor may want to place a post-pyloric tube or a tube that goes all the way past the stomach. It just depends. What would you do if you had a client that needed tube feeding but was unable to keep their head of bed 30 to 45 degrees due to other medical conditions or restrictions? So think spinal cord injury, something like that. So if someone was unable to do that, what we can actually do is we can put their head of bed up, not their actual head of bed, but their bed up where their head is elevated and their body's down, but it's still flat. So instead of putting it like where they're flexed, and this is, it's really hard to put. So instead of like their... Let's see if I can do this with my arms. I was not a cheerleader. I feel like I'm dancing now. I can't do it. So maybe like this. So instead of their head being up like this, it's going to be straight so that it can still maintain their spine while their head is up. Now, like sometimes, for example, someone has to lie flat for short periods of time, like they went to the cath lab, we'll usually just hold their tube feeding until they can sit up. It just kind of depends on how long it is. If it's something more long-term, we'll do other stuff. Or for patients like that, we put prone. that we do not sit up, like ARDS patients on the ventilator. We also sometimes with them put that post-pyloric tube. So sometimes we can also get a tube that's just in farther and that helps. All right, let's see if I can go forward. All right, other complications. So they can also have skin breakdown. So we want to look for skin breakdown around the tube. Like I said, this happens more often lately. There's a lot of device-related pressure injuries. So keep a close eye around that tube. Make sure whatever you're using is least invasive to secure the tube while still keeping it secure because you don't want to lose that tube. It's so not fun to have to put these back in. We talked about them. They can have decreased ability to get their bowels moving. As a result, we can give them medications like metoclopramide. This is a gastric motility agent or it helps to get the bowels moving. And so it increases gastric emptying. In other words, it forces my stomach. the farther part of my stomach to open more or be more open to letting contents out into my intestines. So there's side effects with those. We'll learn about metoclopramide when we talk about nausea, vomiting. So pay close attention because there are some serious side effects with that and some precautions. Hyperglycemia, we're giving them something that has high quantities, usually of sugar because usually we use sugar for calories. We need to keep a close eye. So most of these patients, since they're usually also in PO, all they're getting is the tube feeding. We'll check their blood glucose every six hours or so just to make sure that their sugars are staying stable. And sometimes patients need to be on insulin just because they're on tube feeding. Hypernatremia, because in order to preserve these formulas that we give patients, they have to preserve them just like we preserve our frozen meals with a lot of sodium. So free water flushes, which what I mean by that is if you have anything. Anytime there's too much of one particle in your body, we try to dilute it. So we give extra free water or like literally it's just water from the sink into these. We give them like regular water flushes. So like I said, normally we just flush 30 mils every four hours. But with these patients, it might be every hour, every couple hours, I might be flushing a hundred or a couple hundred in order to get their sodium lower. If they can't tolerate all that fluid, we also can give them D5W, which works a lot the same. It dilutes. And now I know it says D and it's you're thinking, oh my God, that's bad for their blood sugar. It is dextrose, but the way that D5W shows up in your bodies, it just shows up like water. The dextrose is taken on. It usually doesn't, it's not going to increase your blood sugar and it's going to help to flush that high sodium. And then diarrhea. You know, the things that you want to look at for diarrhea is it could be because the tube feeding is going to. fast. So I want to assess if the rate is too fast. Talk to the doctor, especially if it's, if it seems to get better when we pause it or hold it for some reason. And then also checking the expiration because sometimes, you know, people don't want to like it's going at a slow rate, like 10 an hour, and people don't want to waste some of it, but it really shouldn't hang. We usually change them every 24 hours, like my pump, my feeding pump will say like, hey, it's been 24 hours change this. So you definitely want to keep up with that because you do not want it to expire. It can be... very dangerous for the patient and lead to not fun side effects. And then with the diarrhea, of course, just promote hydration, skincare, because you might say hydration, but they already have a liquid stool. But remember, they're losing liquid too. So we want to make sure they're being rehydrated and protect their skin. So watch their skin closely. And then on top of this, a lot of these patients are also at risk for other complications of immobility. So just watching for those as well. I think that's it. Oh, I'm almost done. Last, last thing I want to add is, is just when you're giving meds through tube feed, you want to make sure whenever possible to use liquid. So sometimes when they switch, when someone gets intubated, like I've called the pharmacy and just said, Hey, can you switch any of my meds over to liquid medications? And because it's not actually changing the order, it's just changing the, like the, the type of like the way that the medication is prepared. A lot of times they can switch this over, but sometimes the doctor can also put it in order for you if you want to switch. Like there's a lot of meds that can be given liquid. It'll go so much smoother and better for the patient, saves you time and also helps save your tube. We want to, especially thick medications, dilute them well. So sometimes we give like protein stuff where I work that's super thick. So I'll have to add extra dilution to that. Things to, if you're using a, if you're with tablets, you want to use a pill crusher. This is example of a pill crusher like I have at my work. But they have a variety of different types of pill crushers. Sometimes people have individual pill crushers in their room, or you might have some in the med room. It just depends. But you want to crush it up as thin as possible and then dissolve it in water. And like I said, dilute it well. And then one thing to keep in mind is no extended release medications. I actually had, it came into a problem with this my last summer when I was doing a contract job. Now I give a lot of crushed meds, but I do not give a lot of morphine PO. And I had a patient who was receiving morphine PO and I, um, I went and I, um, they asked, Hey, am I due for it? And I was like, yeah, I'd already crushed all their other meds and, um, got it ready for them. And then I went and I was, I had the morphine separate and I was like, here, here you go. Here's your morphine. And they looked at me like I was crazy. And they were like, you can't crush this. This is extended release. And oh my goodness. It like, they're, they're like, you're not allowed to crush this. I'm looking, I'm like, yeah, I can. And then all of a sudden, like, I'm like thinking in my head and I'm like, wait, why, why, why, why couldn't I crush it? And I was like, what? And all of a sudden it was like, ding, ding, ding. It's extended release. Like it's a long acting medicine. You cannot crush it. And luckily, thank God this patient noticed it. And I'm just saying this because this can happen to anyone, like even someone who's a seasoned nurse. Sometimes you just don't think about these things because it's very routine. But again, I, I don't know if I've ever given, oh, I've never, of course I've never crushed morphine PO, but I've never given morphine PO. I've always given, like I've given Dilaudid PO, other things, but I've never given morphine PO. So I had no idea, but that's why it's your job as the nurse. When you're looking at these meds, look for anything that says ER or SR because SR is sustained release, ER extended release, things like that, or anything that says it's like a 12 hour, you know, formula or something like that. Those are all going to be just a few examples of medications that are not meant to be crushed. On your MAR, it should also say, do not crush this med. And in that case, like this lady, all of her meds were crushed. But she said somehow she could swallow her morphine without it being crushed. So that's why I was so confused. I was like, wait, well, how have you been taking this? And so it was definitely like a humbling lesson for me. And I'm really glad that she was able to pick up on that. But this is why, you know, I'm always fine using myself as an example. Not that I'm out here making a ton of errors all the time, but it's very easy to make errors with this. So because normally pills aren't crushed. So just always double check and make sure it's a pill that is supposed to be crushed. I think that's it. Yes. That is it for enteral nutrition. It is our bedtime, but I'll be back after the crazy fella is in bed for some more videos. See you then.

It can be used for someone who's perfectly nourished, but maybe they can't eat normally right now. So we need to supplement their nutrition. Sometimes we give people mostly enteral nutrition, but they can still eat regular food. Or sometimes people are eating regular food, but we need to supplement that because it's not enough.

So we give them enteral nutrition. And what it pretty much is, this video is going to be about enteral nutrition. I'll have another one about parenteral nutrition.

But enteral nutrition is entering into your body through a tube. So which is why we always so call this tube feeding. And what is happening is pretty much there's...

tube feeding going in through a tube and it gets delivered directly into your GI tract. So you may be wondering like, okay, well, why would someone need this? Why can't we just let them eat?

Well, sometimes people can eat, but they can't eat enough. So someone like with anorexia or that has burns or something else, they maybe need extra nutrition. So that's sometimes why we do tube feeding because they have like, we're not able to meet their nutritional needs just alone with regular food. Sometimes they have...

mental status, other issues like patients that have had strokes, or maybe had a brain injury, other stuff, they may have lost the inability to swallow safely, or they may not be awake enough to eat. Also, people that are critically ill that are like, they have, they're intubated, they have a breathing tube, they may also need tube feeding while they're intubated, because they don't have a way to eat. Otherwise, even though people do try to stick those hamburgers down those breathing tubes, don't do it. And then you also have to consider people that maybe have something going on with their head, face, and neck. So like oral facial cancer, sometimes that can be an indicator for tube feeding or anyone who can't swallow safely.

So think of people who can't swallow safely, maybe they have something going on, maybe there's some sort of obstruction, blockage, permanent or temporary airway going on, and we need to bypass that to get food into their stomach. So patients... in order to receive tube feeding, the one qualifier there, aside from, of course, the need to have it, because we don't just stick these tubes down for fun, is that we need them to have a functioning GI tract. And what I mean by that is they need to have the presence of bowel sounds.

Like, you know, I'm not going to start putting food into a patient that possibly has like an ileus or their bowel, a bowel obstruction, their bowels aren't moving, because it could lead to very, very serious things like, we're going to talk about it soon, but the three P's, pain, perforation, peritonitis. So We definitely don't want to be getting into that. So assessing for bowel sounds before feeding is super important. Tube feeding can be given via bolus, which what that means is that, you know, I'm coming by, we have cans, I'll get a syringe and I will, with gravity, pour in the cans over a short period of time in order to give them kind of like a bolus.

So think of it like a bolus of a medication, like when you're given like an IV push, you're giving it one time, you know, like over a short period of time. And then they might, obviously with a bowl-less feed, they might get it. It would, it would more mimic what we do when we eat, like you and I eat, where like we have three meals throughout the day.

So it's the same kind of thing. It will say to give so many cans throughout the day. Continuous feeding would be when someone gets it via pump, when this is, you know, this is what you're going to see more commonly done, especially with acutely ill people, because sometimes they need to have more nutrient needs, stuff like that. Um, there's... there's mixed theories about it.

Some people say the bolus feeds are better because it more mimics what your body is used to, you know, your body's not used to continually having nutrition going into your stomach all the time. But there's pros and cons having the continuous does help stuff, it is considered like a PPI prophylaxis to some physicians. But then on the downside, you know, elevated blood sugars, overloading the stomach, you know, diarrhea, there's other issues and stuff that could happen. So I'll tell you, most of the time you're going to see it given continuous, but there are some times that it's given bolus.

There's also, of course, if I'm going to give food via a tube, I need a tube. So the tubes you're going to see given, there is an NG tube, which is a nasogastric tube. You can see it here in this picture, goes in through the nose, right or left, doesn't matter, whichever one, it will go down.

There's an OG, which is an orogastric. And you're only going to see this one. An NG is probably going to be the most common one you see. The OG is going to be given only to patients that... have like breathing tube, stuff like that.

Or for some reason they can't go in the nose, but you're not going to see a patient up and talking with like a feeding tube out their mouth. Usually it's going to only be if they have a breathing tube. They'll have that one.

Then there's a Dobhoff. And this one's a specifically, it's a small bore tube. It usually has a wire in it when you place it and it goes in deeper.

It can actually go all the way. And I mean, NG tube can, well, now I've never heard that before. And I'm going to take that back.

So Dobhoffs can go in farther. They can actually go. into the duodenum, which is past the stomach.

So we call it a post-pyloric tube. It's also, like I said, it's thinner, a more flexible tube and stuff like that can be a little bit more comfortable. So most of the time you're going to see an NG tube or a Dobhoff.

And there's not going to be a test question where we're like, which of these tubes is most appropriate for a patient? Because that's not your decision. But I'm just kind of explaining what these tubes might look like and why. And I'll talk more about the Dobhoff and stuff later.

And then there's also a PEG tube. And this is one that's, you know, it's, it's, you're going to see like the tube come out of the stomach. So this is a more of a long-term tube. And so it's going to come out straight from the stomach and it's called, it's different than like a G-tube because we put it in through endoscopy. Whereas the G-tube is more of a surgical tube that go in and insert surgically.

And then a J-tube is a jejunostomy tube. I can't believe I said that right the first time. I'm so proud of myself.

So a jejunostomy tube, this goes in your jejunum, which is in your intestine. So I was talking about with the Dobhoff, we can bypass the stomach. You may wonder, like, why would we want to go all the way in the jejunum or into the duodenum? And the reason for that is that some patients are really high risk for aspiration. And so we're trying to bypass that.

Or sometimes people have these tubes, if they have, when we talk about pancreatitis, we talk about these. because we don't want them to secrete any more pancreatic enzymes. So if we can bypass where they're going to secrete pancreatic enzymes, we want to do this. But long-term people that are really high risk for aspiration, these tubes are preferred because that way we don't have to worry about stuff backing up as easily. Let's see if I can move forward.

Come on. All right, there you go. So what am I going to do to maintain the tube and prevent aspiration? Because aspiration is a very big risk.

So one thing you'll want to know about these tubes, is that there's high risk for them getting pulled out, sometimes inadvertently, inadvertently, on purpose or not is what I'm saying. And then there's high risk for aspiration because I'm giving them kind of continuous feed, sometimes overfilling their stomach. So we always want to assess the tube for patency and correct placement before we give anything.

So what that looks like is when the tubes first put in, like, you know, I put one in the other day in a patient who had one, but I had to replace it. So I took out their old one and I put the new one in. But before I used it for anything, I went and got what's called a KUB or kidneys, ureter, bladder x-ray.

It's an abdominal x-ray. I verified that it was in the right place with that image and not me, but the doctor verified it was in the right place and said it was okay for use. And then as a nurse on a daily or regular basis, what I'm doing then is I'm looking at the tube marking. So you can kind of see it here.

Um, here there's these little markings here on this tube, on this picture. They'll usually have numbers by them too. And then with that, it's going to tell me if it's in the right place. So the nurse will give me a report and say, hey, your NG tube's at 70 in the left nare. And so that I'm just looking that it's in the right place.

Um, and then paint and C2, always want to flush the tube before you put anything else down it. Make sure that it's flushing. Okay.

Just like you would an IV. Um, we maintain the placement with tape or a bridle. And, you know, there's a lot of pressure related skin injuries.

They've created some different devices that allow it to hang off of. And that looks kind of scary when I put my finger like this on my nose, but that allow it to hang off of the nose without putting too much pressure on the skin. What a bridle is, is what is in this picture and what that actually and like, I mean, where I work, nurses can be trained to do this.

But most facilities, I think physicians do it or especially trained team. But what it is, is what do you call it? There's a. a string, you can kind of see it here, this white string, it actually wraps around the septum of the nose.

I remembered it this time. I think when I did a lecture last semester, I couldn't remember the name for septum, but I finally remembered it this time. Maybe it was early this semester.

I think early this semester, I couldn't think septum. So I've redeemed myself finally in life. I can, I can die a happy person because I'm not a complete fool.

All right. So the septum of the nose, it wraps around that. So if a patient tugs on it, all it's going to do is give them the worst headache of their life. And it can't get pulled out. So it's definitely preferred, especially for patients that really are tugging at that thing, because eventually they're not going to want to tug at it, trust me, because I didn't believe it either.

I was like, they're going to just keep pulling. They eventually stop because it hurts. Anyway, so it's wrapped around the septum and you do it with a magnet.

It's actually pretty cool to see, but you do with the magnet to get the two pieces of the two pieces tied together. So it's kind of too hard to explain in a video, but you can look up like bridling and maybe search NG tube bridling because I don't know, like there's so many weird things out there that students have told me, like are dirty things that I didn't know were dirty things. So maybe don't just search bridling because that sounds weird.

Maybe just search NG tube bridling and then see what you find. And hopefully, knock on wood, you won't regret Googling that. But anyway, so taper, bridle, or one of those special securement devices.

Then also assess for bowel sounds before feeding. Like I said, you have to have patent bowels in order to do this. Appropriate client positioning is going to be 30 to 45 degrees if they're continuous feeding, like through a pump. And it's very controversial, or you'll see some nurses that put patients head down to turn them real quick, and they're like... They're going to be fine for the 10 seconds I put their head down.

I usually pause my tube feeding when I put my head down, a patient's head down, just because you never know. But, you know, it may be a force of habit. But, you know, usually I try to pause it if we're, you know, if we're putting them down just to kind of prevent any aspiration that short period of time. But yeah, then if that's for if they're continuous feeding and you really want to keep them at that all the time.

So some patients, they want to lie their head down. You just have to tell them, hey, it's not really safe while you're getting this feeding. For someone who's getting the bolus feeding, you just need to keep them upright for 30 to 60 minutes after.

There's different policies about gastric residuals. So what I'm talking about here is that patients can, you know, the stomach wasn't meant to continuously have food in it. It takes sometimes a while to digest.

You have to think about patients that are receiving this, they're going to be bed bound. They might not be moving or getting around as much. And as a result of that, they can have gastric residual or like they can have more.

food contents or that tube feeding contents in their stomach. And so we caught as a result of this, they can end up being high risk for aspiration vomiting, or pretty much just think like the stomach's getting overfilled. So think of like a bottle of water, we keep pouring in more water, eventually, it's going to overflow, especially if there's not, you know, if we're not emptying well, and a lot of people that again, are immobile, sick, they may have decreased gastric motility. So we can depending on our hospital policy.

Sometimes we check it like, so what I'll do at the beginning of my shift, if I have a regular NG tube, we don't do these usually with doll puffs because they're too thin. And by the way, this is a doll puff, this yellow tube here that's super skinny, where regular NG is usually clear. But with a regular NG, I'll pull back on it and see how much I can get.

Now I've gotten upwards of 500 out of someone's stomach. Usually, I mean, we like there to be nothing, but I want to say you're I don't know if your new book says a certain amount, but usually we like it like less than a hundred or something like that. Maybe a hundred or 200. Let's say it's a hundred or maybe even less than that. But what do you call it?

We usually don't like that much. So if I have a couple hundred in there, sometimes I'll call the doctor and say, Hey, you know, kind of just warns me that like, maybe, you know, and I'm not going to go and play doctor and say, I'm going to hold this feed or whatever, but I'm going to just call the doctor. What do you want to do?

Because sometimes they'll tell me, Hey, don't give back whatever I took out. Um, but the one thing to keep in mind there is if I took out like, let's say 500 cc's of a patient, that's a lot of volume I'm taking out if I'm not putting it back. Cause I know you're probably going to find this disgusting, but if you didn't know this, what I, what I was talking about is, is like, I'll get to the NG tube. I'll literally pull back and see what I can get out of their stomach.

And, um, sometimes it's, uh, like I said, it's multiple hundreds, but after I'm done with it, then I use, I put it right back. So then I suck it back up and then, um, like actually give them back. um, this food or, um, a lot of times it's their gastric acid too. So this is the other thing.

And when we talk about, um, we talked about the beginning of the semester, we talked about acid base imbalances. We mentioned the fact that sometimes if we're sucking out too much of someone's gastric acid, it can lead them to be at risk for, um, you know, certain types like a metabolic alkalosis. I want to say yes.

Yeah. Alkalosis. Yeah.

Cause we're taking out their acid. Um, am I saying that right? Yes.

Yeah. Metabolic alkalosis. All right.

I was having a moment of doubt. And so just be extra cautious. Like if you are somewhat like, you know, I remember when I first started, like I was sitting there and I would take out a couple hundred and the doctor's like, it's fine.

Just give it back. And I was like, oh, but this is so much like I was so worried about it. But remember, you're not just pulling out food from their stomach. You're also pulling out acid.

And so if I take away their acid, they could have acid base imbalances. I'm taking out some of their volume. It can lead to some serious issues. So you're not just taking out one thing there. So you definitely usually want to give it back.

but just check with your physician. And again, it's all about hospital policy. We're not going to give you a question about this because it's not a universal thing. It varies by hospital. Then for general maintenance, we're also going to flush the tube usually about every four hours or so.

And if it's continuous, it's usually going to be programmed in the pump. And then if they get a bolus feeding, you'll do it like before and after just to keep the patency of the tube because that stuff is thick. So you want to make sure to flush it well.

This kind of shows like if the NG tube is not placed. Well, this is where it should be placed here on the left. But if it's not, it can go in the beautiful lungs. You definitely don't want to be feeding in there, which is why you always need to check placement first. All right, so let's look at some questions here.

So what would you do to maintain the patency of the tube while maintaining? So these are some like critical thinking questions. So what would you do to maintain patency of the tube while maintaining a fluid restriction? So think like a heart failure patient.

So to maintain patency of the tube, we said we needed to flush it, but how can I flush it and give that? Do I, like most patients that are heart failure, they're on a fluid restriction. So how do I keep the tube patent while also not overloading the patient is what this question is asking.

So it's all about a balance. The doctor will decide how much free water is given. So but just keep in mind that, like, you know, there's sometimes that I mean, the doctor didn't necessarily order to order you to do it. But let's say you have meds to give through that tube. Hold on a sec.

I'll be done in a few minutes. I'm sorry. My son's waiting for some time together. Anyway, so the doctor, you know, not necessarily ordered this, but anytime you give meds down that tube. you have to flush before and after.

So sometimes they end up getting an in it, like, you know, an unintentional flush. So, but I always try to consider, so if I have a patient who's really fluid overloaded, I try to put the minimal amount of fluid to like mix the meds and the minimal, minimal amount before and after to keep that tube patent. So just trying to keep it simple with those kinds of patients where they still need the tube flushed, but maybe not as frequently. And then, you know, just kind of being cautious because sometimes like I don't even need to regularly flush the tube because I'm regularly giving meds. through the tubes, they're getting flushes automatically.

But that's like not perfect nursing school world, you know, in perfect nursing school world, we want to flush it every four hours. So what would you do if you were unable to flush your NG tube? So this is something you might find kind of cool, but they actually have this. If you like, there's a couple different things that you can do.

If I'm trying to flush and maybe like, cause sometimes people don't crush pills well enough and it clogs your tube. Or sometimes people have very thick secretions and maybe some of their secretions block the tube. What you can do.

Some people just pour soda down it and there's something about the stuff in soda, maybe it's the carbonation or something, it breaks it down. But there's actually like a, these pancreatic enzymes, I think is what we put down that can actually help the tube to flush. And you'd be surprised, it's kind of like when people's, their PICC lines clot off and we put the quick clot in, we let it sit for a little bit and then see if we can flush the tube. But yeah, so sometimes it's kind of a, it's a double edged sword. Because you're trying to push down this pancreatic enzymes into the tube to get it to, you know, to clear out.

But you can't even get that medicine in the tube enough to get it in. But you do the best that you can. But you'd be surprised sometimes how it can get broken down. So, but definitely if you're unable to flush it.

Yes, sir. Dylan, I'll be done soon. So.

Don't mind this. I think this is what makes these videos so realistic because I promise that my family's not paid actors. This is really my life. And I'm usually interrupted a lot more than this.

But anyway, so but the unable to flush the tube, I mean, hopefully, always first make sure it's unclamped all the way. And you know, your stopcock's in the right place. But then you know, you definitely want to try.

You never want to force it. or try to make it more difficult. It's always like heartbreaking when your tube, because sometimes it kinks or something else and you try to move it a little bit, still doesn't work. But then at the end of the day, if you can't flush it, you can't use it.

You're not gonna be able to get anything down in any way. So sometimes you have to take it out and put it back in if the other stuff does not work. There are times, like I mentioned too, sometimes it's not about there's something in the tube, but sometimes the tube gets kinked, especially those thinner Dobhoff tubes. So sometimes I've had to like move it a little bit and then it will start to work.

Um, always re-verify with a new image. So what would you do if you assess your NG tube and it's too far in or too far out? So in cases like that, if my NG tube is too far in, um, what do you call it?

I definitely want to make sure it's still in the right place. And cause sometimes what can happen is you might think, Ooh, I want it super in, but there's times it gets like circled around in the patient's stomach. It can actually clamp off, um, or not be working as well.

We don't want it like suit, like the whole thing in the stomach. Like, you know, we just want. the tip in the stomach.

And like, usually we want it farther in the stomach, but not like, not at the, just at the top, but we don't need to be jamming this thing deep inside of them. So usually if it's too far in, we'll just pull it back a little bit. And usually the radiologist will even say that in the report, they're like, Hey, pull it back this far.

Or the doctor may tell you to do that. If it's too far out, then we can try to push it back in just depending on the situation. I usually check with the doctor.

Hey, do we still want this in? And cause again, people pull on these things. Sometimes on purpose, sometimes not. If it's too far out, then I might, again, I might push it forward and advance it.

And then I'll get another image to make sure that it's still in place. If your client pulled out their NG tube, again, the first thing I do is I make sure, like, do they still need this tube in? Like, is it still necessary? Is this a tube that we're going to be using for the future that we need?

Because sometimes we keep tubes in patients sometimes, you know, and no one ever asked and stops and says like, hey, do we still need this as an indicator? Is there another option? Especially if you have a patient who's like determined and set on doing it. Because I had a patient once that was like, she had a wrist and she was like a 90 pound little woman. Like, I don't know how she had so much strength, but I'll tell you, she was feisty.

And so, but she had mittens on and wrist restraints. And that's what we had to do to keep her NG tube in to feed her. And then like they were planning on bringing her home. So I'm like, well, how's she going to go home?

Like, you know, like what are they going to hold her down with at home? So yeah, it's hard stuff. So you always want to ask like, is this necessary?

We still need this. Is there an alternative? And if there's not, then you just get an order to put a new one in and they get a new image for that. And if I'm like the other day when I had to take one out and put a new one in, I always try to do it in the other nose if I can.

Or in there, excuse me. Not the other nose because you only have one nose. Hopefully, other nair. What would you do if your sudden client receiving tube feeding suddenly develops coarse crackles bilaterally? What could this indicate?

This could indicate aspiration. So if someone that I was taking care of started to get coarse crackles, and I've had this happen before, we usually talk to the doctor, want to get an x-ray. Because I mean, sometimes it can be other processes that lead to that, depending on why the patient's there. But we definitely want to be looking for aspiration.

I want to be checking their head of. bed, make sure that it's elevated enough and make sure that the tube's in the right place. Cause I've had it happen where the tube comes out a little bit.

And so it's just the location of it. It puts them at super high risk cause it's not actually in the stomach, it's in the esophagus. So yeah. So checking placement of everything, positioning in the bed, x-ray to see what's going on and then take it from there. They may need antibiotics if it's aspiration pneumonia.

The doctor may want to place a post-pyloric tube or a tube that goes all the way past the stomach. It just depends. What would you do if you had a client that needed tube feeding but was unable to keep their head of bed 30 to 45 degrees due to other medical conditions or restrictions?

So think spinal cord injury, something like that. So if someone was unable to do that, what we can actually do is we can put their head of bed up, not their actual head of bed, but their bed up where their head is elevated and their body's down, but it's still flat. So instead of putting it like where they're flexed, and this is, it's really hard to put. So instead of like their...

Let's see if I can do this with my arms. I was not a cheerleader. I feel like I'm dancing now. I can't do it. So maybe like this.

So instead of their head being up like this, it's going to be straight so that it can still maintain their spine while their head is up. Now, like sometimes, for example, someone has to lie flat for short periods of time, like they went to the cath lab, we'll usually just hold their tube feeding until they can sit up. It just kind of depends on how long it is. If it's something more long-term, we'll do other stuff. Or for patients like that, we put prone.

that we do not sit up, like ARDS patients on the ventilator. We also sometimes with them put that post-pyloric tube. So sometimes we can also get a tube that's just in farther and that helps. All right, let's see if I can go forward.

All right, other complications. So they can also have skin breakdown. So we want to look for skin breakdown around the tube.

Like I said, this happens more often lately. There's a lot of device-related pressure injuries. So keep a close eye around that tube.

Make sure whatever you're using is least invasive to secure the tube while still keeping it secure because you don't want to lose that tube. It's so not fun to have to put these back in. We talked about them. They can have decreased ability to get their bowels moving.

As a result, we can give them medications like metoclopramide. This is a gastric motility agent or it helps to get the bowels moving. And so it increases gastric emptying. In other words, it forces my stomach.

the farther part of my stomach to open more or be more open to letting contents out into my intestines. So there's side effects with those. We'll learn about metoclopramide when we talk about nausea, vomiting.

So pay close attention because there are some serious side effects with that and some precautions. Hyperglycemia, we're giving them something that has high quantities, usually of sugar because usually we use sugar for calories. We need to keep a close eye.

So most of these patients, since they're usually also in PO, all they're getting is the tube feeding. We'll check their blood glucose every six hours or so just to make sure that their sugars are staying stable. And sometimes patients need to be on insulin just because they're on tube feeding. Hypernatremia, because in order to preserve these formulas that we give patients, they have to preserve them just like we preserve our frozen meals with a lot of sodium. So free water flushes, which what I mean by that is if you have anything.

Anytime there's too much of one particle in your body, we try to dilute it. So we give extra free water or like literally it's just water from the sink into these. We give them like regular water flushes. So like I said, normally we just flush 30 mils every four hours. But with these patients, it might be every hour, every couple hours, I might be flushing a hundred or a couple hundred in order to get their sodium lower.

If they can't tolerate all that fluid, we also can give them D5W, which works a lot the same. It dilutes. And now I know it says D and it's you're thinking, oh my God, that's bad for their blood sugar. It is dextrose, but the way that D5W shows up in your bodies, it just shows up like water. The dextrose is taken on.

It usually doesn't, it's not going to increase your blood sugar and it's going to help to flush that high sodium. And then diarrhea. You know, the things that you want to look at for diarrhea is it could be because the tube feeding is going to.

fast. So I want to assess if the rate is too fast. Talk to the doctor, especially if it's, if it seems to get better when we pause it or hold it for some reason. And then also checking the expiration because sometimes, you know, people don't want to like it's going at a slow rate, like 10 an hour, and people don't want to waste some of it, but it really shouldn't hang.

We usually change them every 24 hours, like my pump, my feeding pump will say like, hey, it's been 24 hours change this. So you definitely want to keep up with that because you do not want it to expire. It can be...

very dangerous for the patient and lead to not fun side effects. And then with the diarrhea, of course, just promote hydration, skincare, because you might say hydration, but they already have a liquid stool. But remember, they're losing liquid too. So we want to make sure they're being rehydrated and protect their skin. So watch their skin closely.

And then on top of this, a lot of these patients are also at risk for other complications of immobility. So just watching for those as well. I think that's it.

Oh, I'm almost done. Last, last thing I want to add is, is just when you're giving meds through tube feed, you want to make sure whenever possible to use liquid. So sometimes when they switch, when someone gets intubated, like I've called the pharmacy and just said, Hey, can you switch any of my meds over to liquid medications? And because it's not actually changing the order, it's just changing the, like the, the type of like the way that the medication is prepared. A lot of times they can switch this over, but sometimes the doctor can also put it in order for you if you want to switch.

Like there's a lot of meds that can be given liquid. It'll go so much smoother and better for the patient, saves you time and also helps save your tube. We want to, especially thick medications, dilute them well. So sometimes we give like protein stuff where I work that's super thick.

So I'll have to add extra dilution to that. Things to, if you're using a, if you're with tablets, you want to use a pill crusher. This is example of a pill crusher like I have at my work. But they have a variety of different types of pill crushers. Sometimes people have individual pill crushers in their room, or you might have some in the med room.

It just depends. But you want to crush it up as thin as possible and then dissolve it in water. And like I said, dilute it well. And then one thing to keep in mind is no extended release medications.

I actually had, it came into a problem with this my last summer when I was doing a contract job. Now I give a lot of crushed meds, but I do not give a lot of morphine PO. And I had a patient who was receiving morphine PO and I, um, I went and I, um, they asked, Hey, am I due for it?

And I was like, yeah, I'd already crushed all their other meds and, um, got it ready for them. And then I went and I was, I had the morphine separate and I was like, here, here you go. Here's your morphine.

And they looked at me like I was crazy. And they were like, you can't crush this. This is extended release.

And oh my goodness. It like, they're, they're like, you're not allowed to crush this. I'm looking, I'm like, yeah, I can. And then all of a sudden, like, I'm like thinking in my head and I'm like, wait, why, why, why, why couldn't I crush it? And I was like, what?

And all of a sudden it was like, ding, ding, ding. It's extended release. Like it's a long acting medicine. You cannot crush it. And luckily, thank God this patient noticed it.

And I'm just saying this because this can happen to anyone, like even someone who's a seasoned nurse. Sometimes you just don't think about these things because it's very routine. But again, I, I don't know if I've ever given, oh, I've never, of course I've never crushed morphine PO, but I've never given morphine PO.

I've always given, like I've given Dilaudid PO, other things, but I've never given morphine PO. So I had no idea, but that's why it's your job as the nurse. When you're looking at these meds, look for anything that says ER or SR because SR is sustained release, ER extended release, things like that, or anything that says it's like a 12 hour, you know, formula or something like that.

Those are all going to be just a few examples of medications that are not meant to be crushed. On your MAR, it should also say, do not crush this med. And in that case, like this lady, all of her meds were crushed.

But she said somehow she could swallow her morphine without it being crushed. So that's why I was so confused. I was like, wait, well, how have you been taking this? And so it was definitely like a humbling lesson for me. And I'm really glad that she was able to pick up on that.

But this is why, you know, I'm always fine using myself as an example. Not that I'm out here making a ton of errors all the time, but it's very easy to make errors with this. So because normally pills aren't crushed. So just always double check and make sure it's a pill that is supposed to be crushed. I think that's it.

Yes. That is it for enteral nutrition. It is our bedtime, but I'll be back after the crazy fella is in bed for some more videos.

See you then.

Transcript for:Understanding Enteral Nutrition Fundamentals

Transcript for:
Understanding Enteral Nutrition Fundamentals