Feeding The Critically Ill Patient

The food must be delivered on time and be of appropriate consistency and composition depending on the patient's illness and condition.

A critically ill patient is a dependent patient and is fed by medical professionals in the hospital room and on the hospital bed. The food must be delivered on time and be of an appropriate consistency and composition depending on the patient's illness and condition.

Feeding a seriously ill patient is one of the main duties of a nurse. No matter how delicious and varied the food in the hospital is, many of the seriously ill accept it with reluctance, even disgust. For them, food can be a burdensome obligation. Deprived of appetite, they usually refuse to eat. Therefore, the nurse must deal with them individually, be able to communicate, be persuasive, patient, show understanding towards their emotional problems related to the change of life and the new way of eating.

The appearance of the nurse, her attentive attitude, her cordiality, the orderly, aesthetically designed and pleasant-smelling food have a positive effect on the appetite of the seriously ill patient. 

Appetite in a seriously ill person

Appetite stimulators are conditioned reflexes associated with precisely defined meal times.

Only exceptionally, the patient should not be woken up for meals during restorative sleep.

Visitors must be limited during mealtimes, and imported prohibited products must be removed immediately. If the patient refuses food, offer him another suitable one. He should chew slowly and not be disturbed.

Daily intake required for adults

An adult patient needs daily food providing about 2500 kilocalories. To be complete, the food should contain about 70 grams of protein, 70 grams of fat and 400 grams of carbohydrates per day. Proteins are given in the form of milk, cheese, eggs and lean meat. Fats are taken in the form of cow butter, vegetable oils (margarine, oil) and fatty sausages (pates).

Carbohydrates are provided by bread, pasta, potatoes, rice. Fruits and vegetables are added to these foods to provide the necessary amount of vitamins and salts.

Fatty meals are often not well tolerated and should be avoided. It is also useful to avoid foods that form a lot of gas in the intestines (cabbage, legumes, onions). Very sweet dishes are also not suitable, as they cause sour belching.

All kitchen technologies (frying, boiling, baking) can be used to prepare the food, if the doctor has not prohibited any of them. When serving food, it is necessary to maintain its appearance - it must be carefully prepared, aesthetically presented, neither in small nor in large quantities.

Meal preparation

Pre-meal preparation is carried out, which concerns the patients, the staff and the environment in the ward.

The preparation of the patients requires that tiring procedures and manipulations be stopped half an hour earlier. The action of painkillers should coincide with the time of feeding. Medicines related to meals should be taken at strictly defined times ( before, during and after meals ). Patients should be encouraged and assisted to perform their physiological needs, to wash their hands, to take a comfortable position in bed or in designated places in the canteen.

The staff must be dressed in special aprons with well-tied hair, washed hands and put on a mask that covers the nose and mouth ( if necessary ). He should be friendly, attentive and patient. Not to be late with feeding the sick under different pretexts. To be familiar with the rules of nutrition and to observe their application.

The environment in the ward should allow patients to eat in peace. Pleasant sensations and perceptions improve appetite and digestion.

The hospital room must be aired before the horseradish to remove all odors. The air temperature should be optimal. The cabinet and the table should be conveniently placed next to the patient's bed. The water in the glasses should be replaced with fresh water. At the request of the sick, non-fatiguing music should be provided.

Accommodation for feeding a patient who can sit up in bed

The patient rises to sit. A pad is placed under the knee sockets. The pelvis, back and lower back are well supported with pillows propped up on the raised bed top. One end of the feeding napkin is fixed around the patient's neck, and the other should cover the envelope of the blanket to prevent crumbs from falling into the bed. The tray with the food is placed on a special table directly in front of him. If the patient is able to feed himself, the nurse helps him if necessary, if he cannot feed himself, he is fed by the nurse.

Accommodation for feeding a sick person who cannot sit up in bed

The patient's head is raised with a pillow, if possible. Place a napkin. The patient turns slightly to the left or right side. His back is supported by a pillow. The food tray is placed depending on the situation. Solid foods must be cut into pieces beforehand. If necessary, the nurse assists the patient in feeding.

A paralyzed patient is also placed in a slightly lateral position. Because of the paralysis, there is a danger of food getting into the trachea. The nurse must be very attentive and patient, as the sick eat very slowly. If the food is solid, it needs to be crushed and warmed if it gets cold. Liquids are given with a small spoon that is directed and poured onto the inside of the cheek to avoid choking.

After feeding the patient, the nurse cleans his napkin of crumbs and folds it. Serving is done quickly and without noise. Seeing the dishes, the nurse must understand how much food the patient has taken. If he refused to eat, she should clarify the reasons - whether it was due to lack of appetite or he did not like the food. In the latter case, it is necessary to offer him another food suitable for the diet, to notify in both cases the treating or duty doctor; to help the patient to rinse his mouth, to provide him with rest after eating.

Giving fluids by mouth to a seriously ill person

The patient must be provided with the necessary amounts of fluids and nutrients. Lack of fluids in a short time causes disturbances in blood circulation, kidney function and metabolism.

The patient's desire to drink fluids must always be satisfied. It is necessary to combine and change the drinks, offering tea, weak coffee, lemon juice or other fruit juices and nectars at different times of the day. Milk drinks, which provide protein substances and vitamins, should not be missed.

There are few diseases in which the doctor prohibits or temporarily limits the intake of fluids. If a special diet is not prescribed, the patient's food should be composed in such a way as to ensure sufficient intake of nutrients and vitamins. Overfeeding or underfeeding the patient should not be allowed.

Many diseases occur with loss of fluids and salts; with abundant and frequent vomiting, diarrhea, blood loss, burns, high fever. The supply of fluids necessary for the body is of decisive importance for the outcome of the disease. This is done naturally – by mouth and through intravenous infusions. The fluids that are prescribed, in terms of quality and quantity, depend on the severity of the disease.

The nurse's task is to adequately hydrate the sick according to the doctor's appointment. She monitors the amount of fluids taken in and released, entering them on a special sheet in the column for water balance. He gives fluids to the patient in small portions every 5-10 minutes, 1-2 tablespoons each, so as not to burden the stomach and cardiovascular system. The most suitable for rehydration are weak tea, physiological solution, fresh milk, juices warmed to room temperature.

In the evening, it is preferable to give liquids with a soporific effect: for example, warm fresh milk.

Patients take liquids best with a plastic tube placed in a cup, or with a spoon when they are unable to suck.

Patients who are conscious: it is best to take liquids with a straw or a spoon, from a glass, sipping the liquid in sips. 

Unconscious patients: most often fed parenterally.

The task of the nurse is to observe the critically ill who are conscious and for signs of thirst - whether it is normal or not. It is necessary to eliminate the external causes: excitement, very dry or hot air, taking in the excess amount of food brought in by visitors, physical efforts and others. She must recognize the pathological thirst caused by diarrhea, high fever, diabetes mellitus, profuse sweating, etc., and promptly report her observations to the attending physician.

PREMIUM CHAPTERS ▼

ARTIFICIAL FEEDING (PREMIUM)

Artificial feeding is used when natural feeding is impossible or insufficient and in patients who stubbornly refuse to take food.

The essence of artificial nutrition consists in introducing food, liquids and drugs into the body in an unnatural way. It can be carried out through a tube inserted into the stomach through the nose, through a gastric or intestinal fistula, parenterally, and through nutritional enemas.

Feeding a patient through a tube is used in severe damage to the central nervous system with a violation of the act of chewing and swallowing, in unconscious patients; in comatose states associated with uremia, liver failure, diabetic coma; burns; with injuries of the oral cavity and esophagus; after operations in the area of ​​the swallow; in mentally ill patients who stubbornly refuse to eat; in patients who do not take enough food by mouth and others.

It is contraindicated in diseases of the upper part of the digestive tract (oral cavity, pharynx, esophagus, etc.), which do not allow the introduction of a probe through the nose; strong vomiting with regurgitation of stomach contents ( involuntary return of esophageal or stomach contents back to the oral cavity ), which creates the possibility of its falling into the trachea and hence the danger of asphyxiation; intestinal paresis following abdominal operations. 

The food that is introduced through the tube is made up according to the principle of complete nutrition with a normal content in a quantitative ratio of proteins, carbohydrates, mineral salts, slightly increased vitamins, low in fat and sodium; it must be well tolerated by the patient and not irritate the gastrointestinal tract; to be of excellent homogeneity, beaten with a mixer and strained through a fine strainer; easy to prepare. Food mixtures are not sterile, therefore they must be prepared immediately before feeding. Start with small amounts ( 50 ml )   and correspondingly lower caloric content. A sudden increase in the amount of food can lead to diarrhea and vomiting. Therefore, start carefully with tea or diluted milk and gradually move to a full meal with an increase in the dose (up to 300 ml ) . The ultimate goal is ( if possible ) to switch to eating in a normal way.    

Preparation of the situation:

• that the room is cleaned, ventilated and warm;

• to put up a screen.

 

Preparation of the patient:

• the nurse informs the patient about the upcoming meal and reassures him;

• depending on the condition of the patient, it can be in a sitting or lying position, with the upper part of the body slightly raised to protect against aspiration;

• a towel is placed around his neck and his underwear is covered with a tarpaulin.

 

Necessary accessories:

The necessary tools are placed on a trolley:

• sterile duodenal probe;

• syringe with a capacity of 250 ml.;

• heated food up to 37 degrees - liquid, semi-mushy;

• probe clamping tool;

• glycerin for moistening the probe;

• syringe for aspiration 10-20 ml. (when the probe is blocked);

• glass of water;

• renal pelvis;

• tarpaulin;

• napkins and towel;

• band aid and scissors.

The probe can be placed in a container of water to make it harder.

 

Performance technique:

1. The nurse informs the patient about the upcoming meal.

2. The nurse inspects the nasal passages and, if necessary, cleans them.

3. The food is introduced quickly but smoothly, not in spurts and continuously, taking care not to introduce air.

4. Finally, the required amount of water (rinse) is introduced.

5. The probe is pinched with an instrument and attached to the cheek or forehead with a plaster.

6. Before each meal, it is necessary to check the position of the probe.

7. When removing, the probe is pinched with an instrument to prevent food from entering the trachea.

8. The nurse cleans the tube with a strong stream of running water to keep it from clogging with food debris.

9. Cleans and puts away other accessories.

10. After the meal, the nurse notes in the notebook the composition and quantity of the food taken and how it was tolerated by the patient ( diarrhea, vomiting, etc. ). 

 

It is dangerous if the tube gets into the trachea. This causes a severe disturbance in breathing due to spasm of the respiratory tract, coughing, bruising. In unconscious patients, these symptoms may be mild or not present at all. Therefore, it is necessary for the nurse to be experienced and to carry out the manipulation very carefully. The correct position of the probe is established by aspiration or by introducing air and simultaneous auscultation in the stomach area.

If there is evidence of food retention, gastric lavage may be performed. Wait for the patient to calm down, insert the tube and start feeding.

Artificial continuous drip feeding ( gurotte a gutte ) by tube is considered dangerous and is no longer practiced. The reason is that no physiological stimulation of peristalsis can be obtained from stretching and the food mixture can accumulate in the stomach.    

Feeding the patient through a gastric or intestinal fistula is used in case of complete obstruction of the esophagus due to burns, malignant tumors and others.

Stomach fistula is done surgically. The operation is called a gastrostomy, and the opening a gastrostomy. The probe is introduced into the stomach through the fistula.

If it is not possible to use a gastrostomy, tube feeding is often carried out through an enterostomy (intestinal fistula), for example, in case of a disease of the exit part of the stomach with a violation of its conductivity or in case of a complete defeat of the stomach. 

Food in both cases is liquid, semi-liquid and mushy. It is better absorbed by the body.

The method of feeding is the same as feeding with a tube through the nose, but the unpleasant sensations are absent.

The patient should isolate himself in order to feel more relaxed, in a sitting or lying position. Food is infused with moderate pressure. Care is taken not to contaminate the external opening of the fistula with food. Therefore, the probe is attached to the skin with a plaster. After each meal, it is washed and closed with a cap. The skin around the fistula is cleaned, smeared with zinc paste to prevent irritation, and covered with a dry, sterile dressing. With longer use of this feeding method, the probe is changed twice a week in order to protect it from the effects of gastric juice. If the tube is expelled from the stomach, the nurse should not attempt to reinsert it. In such a case, she must call a doctor.

Parenteral nutrition is carried out by intravenous drip infusions. It consists in introducing a number of solutions containing nutritional ingredients, electrolytes and vitamins into the body via a venous route. It is used when natural or artificial nutrition is impossible and insufficient.

The duration of this type of feeding depends on the condition of the patient and is strictly assessed by the doctor.

Venous nutrition takes a long time, no less than 8  hours a day. If the patient is only on parenteral nutrition, it is necessary to receive all nutritional ingredients that provide his energy and plastic needs.

Important conditions for the effective absorption of substances introduced into the body are:

1. Simultaneous entry of the plastic and energy components in the volume of the liquid that is infused, without exceeding the daily needs.

2. Nutrient mixtures should be introduced at a certain rate (optimally 60-70 drops per minute, which allows to infuse up to 5 l in 24 hours ) .    

3. Selection of appropriate veins and method of infusion (it is best by cannulation of the upper vena cava ( v . cava superior ) , ) through the external jugular vein ( v . jugularis externa ) or the subclavian vein ( v . subclavia ) .      

Monitoring the patient's condition during the entire period of parenteral nutrition includes:

• daily body mass check ( if possible ); 

• measurement of the amount of introduced and separated liquids ( water balance ); 

• monitoring of vital functions ( pulse, breathing, temperature, etc. );

• determination of the level of sugar and acetone in the urine, the content of sodium, potassium, chlorine, calcium, phosphorus and glucose in the blood according to a doctor's prescription.

Complications:

• thrombophlebitis;

• local infection and sepsis;

• metabolic disorders ( hypoglycemia, impaired liver function, etc. ); 

• embolism.

Contraindications:

• acute renal failure;

• liver and cardiovascular failure;

• hyperhydration of the body;

• thromboembolism and others.

 

Preparation of the patient:

• the nurse informs the patient about the upcoming manipulation;

• the patient has fulfilled his physiological needs;

• to give him the most comfortable position in bed.

 

Preparation of the nurse:

• it must be clean, neat and welcoming;

• to be with washed and disinfected hands;

• to be able to communicate with patients.

 

Necessary accessories:

Everything you need for an IV drip:

• plate covered with lignin;

• alcohol 75;

• container with cotton swabs;

• sterile gauze;

• sterile closed system;

• bus;

• bandage;

• band aid;

• scissors.

• Esmarch.

• tripod.

• tarpaulin and lignin.

• renal pelvis.

• solution containing essential nutrients, electrolytes and vitamins.

 

Performance technique:

Each injection represents mental and physical trauma for the patient. That is why he must be very well prepared for this. For this purpose, you need:

1. Mental preparation of the patient. With an individual approach, depending on the age and condition of the patient, the health care specialist familiarizes the patient with the essence of the manipulation, its importance for his treatment and his behavior during the injection, dispelling his fear and reassuring him.

2. Obtaining informed consent from the patient to perform the manipulation.

3. Ensuring relative physical and mental peace of the patient. In fearful patients and patients with delirium, performing the manipulation requires good immobilization (fixation) due to the reaction from the pricking, because with sudden movements of the patient, the needle can break and remain in the tissues.

4. The health care professional washes and disinfects his hands.

5. The patient assumes a supine position.

6. Determining the vein to puncture.

7. Placing a tarpaulin under the seat.

8. Tightening with an esmarch 5 cm above the designated place, the ends of which are tied in a "key" in the direction of the shoulders.

9. To achieve a better filling of the venous vessel, asking the patient to make a fist, which he contracts and releases.

10. Disinfection of the selected place with an alcohol tapmon from the periphery to the center (from bottom to top).

11. Fixing with the tip of the thumb and forefinger of one (left) hand and slightly stretching the skin over it.

12. Inserting the needle into the vein with the other (right) hand:

• with well-pronounced veins - at one stage;

• in badly protruding veins - in two stages: first it penetrates into the subcutaneous tissue of the vein; then into its lumen (the vein itself). At the first moment of introduction, point the needle at an angle of 30  -  40 and then, penetrating the lumen of the vein (it feels like a sudden decrease in resistance and the entry of blood into the needle head), the angle is reduced to a minimum and the needle is moved by light pressure into the venous lumen, almost parallel to the skin.

13. After entering the lumen of the vein, the elastic bandage is relaxed slowly so as not to change the position of the needle.

14. Fixation with plaster.

15. Introduction of the medicinal solution at an appropriate speed.

16. Observe the patient for subjective complaints and the application site for possible swelling.

17. After introducing the drug, the needle is removed with a quick movement under an alcohol cotton pad along the axis of the vein parallel to the surface of the skin to avoid injury to the vessel wall.

18. Press the puncture site with a cotton pad soaked in alcohol for 3-5 minutes.

19. The patient remains in a supine position for at least 10 minutes after the manipulation.

 

At the smallest signs of swelling, which means that the solution does not fall into the lumen of the vein, but around it, the manipulation is interrupted and another suitable vein is punctured.

As a result of the resulting chemical reaction, a compound harmless to tissues is formed. This condition can cause slight discomfort to the patient, and requires treatment with a rivanol compress for a certain time.

Feeding by subcutaneous infusions is no longer used in medical practice. It has been completely replaced by intravenous feeding.

Rectal feeding is rarely used. Nutrient solutions are introduced into the rectum by enema, jet or drip. As a result of the existing antiperistalsis, they may even reach the small intestine.

A prerequisite is the performance of a cleansing enema, which provides an opportunity for more complete absorption of the nutritional ingredients into the body.

In one day, 3-4 meals can be taken rectally, at intervals of 3-4 hours, in order not to irritate the mucous membrane of the large intestine.

The nutrient solution should not exceed 250-300 ml. Isotonic solutions and glucose are used most often.

Rectal nutrition has been superseded by parenteral nutrition.

 

OBSERVATION AND CARE OF THE PATIENT'S CONDITION (PREMIUM)

OBSERVATION AND CARE FOR THE CONDITION OF THE PATIENT, FOR THE FUNCTIONS OF SEPARATE ORGANS AND SYSTEMS AND THEIR DISEASE CHANGES. OBSERVATION OF THE FACIAL EXPRESSION OF A SICK.

 

The nurse, regardless of which hospital department she works in, has the most immediate and long-lasting contact with the patient.

One of her main tasks is to monitor the physical and mental state of the sick, to detect the changes that have occurred in a timely manner and to report them to the treating doctor or the doctor on duty.

In order to perform this function, the nurse must have general culture, high medical qualifications, psychological training, keen observation and intelligence. With her observation and timely messages, she assists the doctor in clarifying the diagnosis and treatment of the patient and can prevent severe complications in his condition ( acute hemorrhage, acute cardiovascular weakness, etc. ). 

The nurse's observation refers to the patient's facial expression, reactions, sense of self, the position he occupies in bed, the state of his movement, and others.

When a person is healthy and has good self-esteem, his face has a good appearance, the skin is smooth and elastic, its color is pink or dull, the eyes are calm and moderately bright, the lips are smooth, the facial expression is moderate.

The patient's sufferings related to various diseases leave an impression on his face. Long-term illnesses affect his mental and physical condition. The skin on the face becomes pale, very red or bluish. Eyes are shiny or darken. The skin is dry or moist, covered with a cold, clammy sweat. In some diseases, the patient's face acquires features characteristic only for them, a special expression. This has led to the identification of the following characteristic facial expressions:

Febrile ( febrile ) ( facies febrilis ) – red, turgoescent, with shiny eyes, dry lips, slight swelling. Breathing is accelerated; the patient is carried away, sometimes restless, may be delirious. Such a face is observed in temperature conditions.   

Hectic face ( facies hectica ) . It is characterized by large and shining eyes, pale cheeks, in the middle of which a round, red spot is sharply outlined. Lips are red and moist. Such a face has a beautiful appearance, but it is a bad indicator. It occurs in patients with a severe form of tuberculosis.  

Facies dyspnoica ( facies  dyspnoica ) – pale, covered with cold sweat. The lips, tip of the nose and ears are bluish (cyanotic). The patient has a frightened look. Nasal gills are also involved in breathing. In advanced heart failure, the face is puffy, the cheeks are red, and the color of the rest of the skin is blue-yellowish. Patients breathe thirsty, with their mouths open.

Facies abdominalis or hippocratica ( facies  abdominalis  s . hyppocratica ) - the skin of the face has lost its turgor, the eyes are sunken in the sockets, surrounded by dark circles, the nose is pointed, the lips are elongated, cold ears. The skin is cold, gray-pale, moist cyanotic, covered with large drops of cold sweat. The face is expressionless. It occurs in severe abdominal diseases ( peritonitis, intestinal obstruction, etc. ).  

Facies neurosis ( facies neurosa ) . This face has a lively expression and restless twitching of the facial muscles. The color of the face changes rapidly and constantly - pale and red. Pupils are wide and react vividly. The gaze quickly moves from one place to another. 

Masked face. It is the complete opposite of nervous. Due to the limited mobility of the facial muscles, the patient's face is frozen like a mask. Does not react or hardly reacts to external irritations. It occurs in patients with depressive mood changes, with Parkinson's disease, in patients with encephalitis.

Facies sardonicus ( risus  sardonicus , from Greek - bitter laughter). Due to a spasm of the facial muscles, one gets the impression that the patient is crying with the upper part of his face and laughing with the lower part. Occurs in tetanus disease.

In addition to the face, the patient's reactions to procedures and manipulations and others are monitored. When they are inadequate, notifies the doctor.

Self-esteem is an important indicator of the patient's condition. In some cases, it does not cover the real situation. The nurse must be aware of the development of the disease state in order to prevent unwanted consequences and complications from non-compliance with the regimen, treatment and others.

 

Particular attention is paid to the patient's position in bed, to his movements, providing appropriate care.