GROUP I: HOA, THAO, AN, BA, LIEU, HANH CASE STUDY You are caring for an 82-year-old woman

who recently transferred to hospital from a nursing home with the diagnosis of presumed nursing home acquired pneumonia. She has a nasogastric feeding tube in place and is lethargic, dehydrated, and confused. 1. 2. 3. 4. 5. What strategies would you initiate to prevent aspiration? What nursing care interventions would you use to assess for aspiration? What is the evidence base for the interventions that you consider? How will you evaluate the strength of the evidence? What suggestions might you have regarding appropriate devices for long-term enteral feeding in this patient once she is discharged back to the nursing home?

1. Prevention of aspiration during tube feeding: Keep the beds backrest elevated to at least 30 during continuous feedings. Maintain a head elevated position for one to two hours afterward. Lying with her lateral face to drain fluid from her mouth. When the tube-fed person is able to communicate, ask if any of the following signs of gastrointestinal intolerance are present: nausea, feeling of fullness, abdominal pain or cramping. These signs are indicative of slowed gastric emptying that may, in turn, increase the probability for regurgitation and aspiration of gastric contents. Measure gastric residual volumes every 4 to 6 hours during continuous feedings and immediately before each intermittent feeding. . Amount of food is appropriate (such as greater than 200 ml) should raise concern (McClave, et al, 2002). A prokinetic agent (such as metoclopramide and erythromycin) may be prescribed to alleviate persistently slowed gastric emptying (McClave, et al, 2002). Post-pyloric placement of the feeding tube (jejunostomy) may be prescribed if persistently slowed gastric emptying is a problem (McClave, et al, 2002). The efficacy of this action is controversial. Pump assisted feedings may be associated with fewer aspiration events than are gravitycontrolled feedings in bedridden patients with gastrostomy tubes (Shang, et al, 2004). To prevent aspiration, you must check the tube placement before each feeding, to be sure it has not moved. Look at your patient. Is your patient comfortable and breathing normally? If she appears distressed, is coughing, or cannot talk, remove the tube. Do not start the feeding. Make sure that the mark on the tube is at the nostril. Measure the tube from the mark at the nostril to the beginning of the hub and make sure it matches the extra tube length number you wrote down earlier. Try to pull out some stomach fluids with the syringe. 2. What nursing care interventions would you use to assess for aspiration? Cough Fever, breath rate change: shortness breath Sputum characteristics: amount, color, smell Crackles

4. How will you evaluate the strength of the evidence? Maintain her weight Absence the aspiration No fever No changes sputum characteristics 5. Discharge for the patient when she comes back to the nursing home Care of feeding bag and tubing: Change every day. After each use, wash with warm water and dish soap, rinse well with clear water, and store in refrigerator. If the bag and tubing do not clean easily, try using a solution made of equal amounts of white vinegar and cool water (for example 1 cup vinegar with 1 cup water). Rinse well and store in refrigerator. Throw away the feeding bag and tubing after 1 week; sooner if you cannot get it clean or if it begins to leak.