1 00:00:04,389 --> 00:00:09,349 This skill is enteral feedings. This is a skill that we have to do for people that cannot 2 00:00:09,349 --> 00:00:13,470 eat by mouth and usually it's long term when we're doing the gastrostomy tube. You can 3 00:00:13,470 --> 00:00:17,789 also do it by the nasal gastric tube, but since most of our folks in the nursing centers 4 00:00:17,789 --> 00:00:22,309 where we'll be going this semester are gastrostomy tubes, then we're going to be doing it through 5 00:00:22,309 --> 00:00:26,030 the gastrostomy tube. The first thing you want to do is check the chart again and you're 6 00:00:26,030 --> 00:00:31,289 looking to see what type of formula, is it full strength, the amount, the time, the frequency 7 00:00:31,289 --> 00:00:35,850 of it. Also, you want to look and see how they've been tolerating it before, because 8 00:00:35,850 --> 00:00:40,130 if they've had issues with residual as far as how much was left in their stomach before 9 00:00:40,130 --> 00:00:45,009 you start the feeding each time, then you might want to take and be extra careful about 10 00:00:45,009 --> 00:00:49,750 what you give them and how you assess them. Not that we wouldn't be careful anyway. Once 11 00:00:49,750 --> 00:00:52,929 I get through with the chart again, I've checked the allergies, worried about latex again, 12 00:00:52,929 --> 00:00:56,670 I'm worried about food allergies. In this case, we're going to give Ensure, and we're 13 00:00:56,670 --> 00:01:00,609 going to give 50 milliliters of Ensure this time when we come down. And sometimes the 14 00:01:00,609 --> 00:01:04,950 The doc will order specific water, when we should give water and how much. 15 00:01:05,150 --> 00:01:06,890 So you always want to look at that also. 16 00:01:07,390 --> 00:01:10,150 Okay, now you want to go and wash your hands and gather your supplies. 17 00:01:10,590 --> 00:01:14,769 We're going to use a stethoscope because we may need to listen to lungs in the abdominal area. 18 00:01:15,250 --> 00:01:19,609 You're also going to have a pad to protect them so if we spill, we don't get them wet. 19 00:01:20,129 --> 00:01:23,969 Gloves, we have the Ensure here, and then we have regular tap water. 20 00:01:23,969 --> 00:01:27,450 And it's Tippett, not hot, not cold water that you've got there. 21 00:01:27,629 --> 00:01:30,530 And we've got our pH paper to check placement. 22 00:01:30,609 --> 00:01:34,930 And we also have an irrigation bottle with a syringe here. 23 00:01:35,709 --> 00:01:37,010 Come down to the room. 24 00:01:37,189 --> 00:01:38,349 You want to take and come in. 25 00:01:38,409 --> 00:01:39,590 You want to identify your patient. 26 00:01:39,730 --> 00:01:40,609 This is Mrs. Johnson. 27 00:01:41,170 --> 00:01:42,049 I'm Ruth Miller. 28 00:01:42,390 --> 00:01:44,650 I'm going to be giving you two feeding to you today, 29 00:01:44,650 --> 00:01:48,329 so I want to explain everything I'm going to be doing to her before we start. 30 00:01:48,969 --> 00:01:50,709 Then I want to provide privacy. 31 00:01:51,409 --> 00:01:55,489 If you haven't done so, you may want to go ahead and do a quick abdominal assessment. 32 00:01:56,250 --> 00:01:57,909 Again, you're listening for bowel sounds 33 00:01:57,909 --> 00:02:00,829 because you always want to have bowel sounds if you're going to be feeding someone. 34 00:02:01,310 --> 00:02:04,109 Okay, once you get finished with that, you want to look at the general skin color 35 00:02:04,109 --> 00:02:07,209 to know what their normal skin color is in case they run into trouble 36 00:02:07,209 --> 00:02:09,349 because if we run into trouble with this skill, 37 00:02:09,449 --> 00:02:12,409 it's going to be aspirating into the lung, abdominal distension. 38 00:02:12,569 --> 00:02:15,870 So do a respiratory assessment, color, how well they're breathing, 39 00:02:16,389 --> 00:02:22,370 and how often they're breathing, 16 to 20 a minute, nice, easy, regular, no distress, 40 00:02:22,750 --> 00:02:24,330 and the abdominal area for distension. 41 00:02:24,710 --> 00:02:28,509 Once you get through with that, then you want to go ahead and gather everything you've got. 42 00:02:29,069 --> 00:02:33,849 What I've got here is I want to hit and measure the water out, and I want to hit and measure the Ensure out. 43 00:02:34,770 --> 00:02:38,610 Ensure lots of times will come in a 240-milliliter can. 44 00:02:39,009 --> 00:02:44,189 If you're not going to use it all, you can take and put a cup of tape over it and save it for eight hours. 45 00:02:44,189 --> 00:02:47,569 But normally, as a rule of thumb, what we don't use, we usually toss out. 46 00:02:49,830 --> 00:02:53,669 So now we've explained what we're going to do, and she's happy to go along with us. 47 00:02:56,479 --> 00:02:58,580 We're going to go ahead and get our gloves on. 48 00:02:59,020 --> 00:03:04,860 Very important that we put the head of the bed up, and she's in an up position, so that's good. 49 00:03:05,300 --> 00:03:11,960 Only expose what we need to, and I've got the curtain pulled, so I still try not to expose any more than I have to. 50 00:03:12,360 --> 00:03:25,849 And in this case, this is our gastrostomy tube here, and I want to go ahead and move everything over so I'll be able to reach it. 51 00:03:25,849 --> 00:03:38,090 Now, what you want to do here is to take and instill 30 milliliters of air, and I'm going 52 00:03:38,090 --> 00:03:39,150 to clamp this off. 53 00:03:39,150 --> 00:03:41,389 This is just like the nasal gastric tube. 54 00:03:41,389 --> 00:03:45,310 Every time you take the plug out, you want to clamp it off so they don't wind up sucking 55 00:03:45,310 --> 00:03:48,449 a bunch of air in their tummy and getting distended. 56 00:03:48,449 --> 00:03:51,150 Once I get this in, I can open it up. 57 00:03:51,150 --> 00:03:56,550 Now put your cap, your plug, on the bed, because otherwise if you don't, you're going to be 58 00:03:56,550 --> 00:03:58,889 chasing it around in the floor. 59 00:03:58,889 --> 00:04:01,530 Now we want to go ahead and put these in. 60 00:04:01,530 --> 00:04:05,830 We're going to listen anywhere around the gastrostomy tube, and you want to push it 61 00:04:05,830 --> 00:04:06,969 in quickly. 62 00:04:06,969 --> 00:04:11,710 And what you should hear is the gastric sound, you'll hear a swoosh. 63 00:04:11,710 --> 00:04:18,350 Now we want to aspirate back, and we're going to say that this time, checking the residual, 64 00:04:18,350 --> 00:04:20,209 how much is left from the last feeding. 65 00:04:20,209 --> 00:04:25,970 like maybe about 5 milliliters. When I pull this out, because now I need to check the 66 00:04:25,970 --> 00:04:31,350 pH, again I've got it clamped, I'm going to plug it off and leave it right there. I will 67 00:04:31,350 --> 00:04:37,050 take my pH paper here and just hold it over the garbage can, shoot a little bit of the 68 00:04:37,050 --> 00:04:44,509 gastric contents on it, and again compare it to my paper here, and it looks like we're 69 00:04:44,509 --> 00:04:51,509 at a 4, 4.5, that's our pH. So that's great because that's a good indication that we're 70 00:04:51,509 --> 00:04:56,569 in the abdomen. We only have 5 cc's back of residual, that's how much that was left from 71 00:04:56,569 --> 00:05:01,910 the last feeding, which is good. Your book recommends anything 200 or above to clamp 72 00:05:01,910 --> 00:05:07,529 the tubing and the hole or to follow your policy wherever you're at working. Now, the 73 00:05:07,529 --> 00:05:13,689 next thing we want to do, and we usually let all of this run by gravity. We don't want 74 00:05:13,689 --> 00:05:20,089 to force anything into the abdominal area. Again, clamp it off. Put your plug over on 75 00:05:20,089 --> 00:05:25,310 the table. We're going to insert this. Now, this is an open system that I've got here. 76 00:05:25,870 --> 00:05:31,250 And what I'm going to do is add 30 of water. And the reason why I'm doing that is to make 77 00:05:31,250 --> 00:05:36,449 sure it'll flush what I aspirated back up through and that everything's going to go 78 00:05:36,449 --> 00:05:42,730 through fine. Okay, the higher I hold it, the quicker it'll run. Okay, I try to clamp 79 00:05:42,730 --> 00:05:47,970 it off so that they do not get any air. She looks fine. It looks like everything is working 80 00:05:47,970 --> 00:05:54,350 well. Now I am going to turn this around and I am going to put 50 ml of Ensure in. She 81 00:05:54,350 --> 00:05:59,670 has got a little multivitamins here too it looks like. You can kink it off to slow it 82 00:05:59,670 --> 00:06:07,730 up or raise it and lower it. If you look right here where my finger is, you can see how fast 83 00:06:07,730 --> 00:06:11,649 it is going down. You can talk with her while you are standing there, you know, how was 84 00:06:11,649 --> 00:06:15,970 the night? What did you watch on TV? When was the last time you saw your children? Were 85 00:06:15,970 --> 00:06:21,370 they in yesterday? Just anything to help pass the time. But you want to run this in, and 86 00:06:21,370 --> 00:06:26,589 it should take about one to two milliliters every couple of seconds to go in. And as you 87 00:06:26,589 --> 00:06:32,069 can see, when I raise it, it runs fast. When I lower it and kink it, it slows it up. And 88 00:06:32,069 --> 00:06:35,389 when I get down to about two to three milliliters, I'm going to clamp it off because I don't 89 00:06:35,389 --> 00:06:40,209 want a bunch of air in her tummy. I'm going to follow off with 30 milliliters of water, 90 00:06:42,509 --> 00:06:44,649 And I got this from my chart from the order. 91 00:06:45,170 --> 00:06:48,430 Now, when this goes in, I'm going to let it run all the way down to there. 92 00:06:53,519 --> 00:06:55,040 And then I'll clamp it off. 93 00:06:55,579 --> 00:06:56,680 Okay, there you go. 94 00:06:57,180 --> 00:06:58,060 Clamp it off. 95 00:07:01,680 --> 00:07:04,959 Make sure she's still doing okay, feeling all right. 96 00:07:05,240 --> 00:07:06,279 Stomach looks good. 97 00:07:06,560 --> 00:07:07,579 Respirations look good. 98 00:07:07,720 --> 00:07:08,980 Skin color looks good. 99 00:07:09,720 --> 00:07:15,079 I'll clean all of this up and put this back, put her gown down, pull everything up here. 100 00:07:15,759 --> 00:07:17,399 See if she needs anything. 101 00:07:17,660 --> 00:07:19,220 if there's anything that she needs. 102 00:07:19,579 --> 00:07:22,939 If she doesn't, then I'll put the bed back down in the low position. 103 00:07:23,439 --> 00:07:27,519 It's best to leave the head of the bed elevated for 30 minutes after you feed someone. 104 00:07:27,920 --> 00:07:31,920 If you think about it, you wouldn't go to bed right away after you finish eating a heavy meal. 105 00:07:32,259 --> 00:07:35,800 So leave the head of the bed in the high fowler's position, which is most crucial. 106 00:07:36,319 --> 00:07:38,860 When lawsuits come over this particular scale, 107 00:07:38,860 --> 00:07:41,899 it's usually because we didn't put the bed up high enough and they aspirated, 108 00:07:42,220 --> 00:07:45,759 or we put the bed back down too soon in the head of the bed and they aspirated. 109 00:07:45,759 --> 00:07:49,939 So, the head of the bed needs to stay up for at least 30 minutes until she set time to 110 00:07:49,939 --> 00:07:54,459 digest some of it, and then you can come back in 30 minutes to check her and make sure it's 111 00:07:54,459 --> 00:07:56,980 all right and put the head down. 112 00:07:56,980 --> 00:07:59,519 In the meantime, though, go ahead and clean everything up. 113 00:07:59,519 --> 00:08:03,240 Anything left over gets put in the commode. 114 00:08:03,240 --> 00:08:09,120 The syringe gets washed out, which is regular tap water, and then it should be in a bag 115 00:08:09,120 --> 00:08:14,339 that's left apart and put in a bag to dry, and we change these syringes out in the irrigation 116 00:08:14,339 --> 00:08:20,699 tray itself every 24 hours. Okay, everything's cleaned up. She doesn't need anything else. 117 00:08:20,699 --> 00:08:23,019 I'll wash my hands and I'll go and document now.