Peripheral vascular assessment

Peripheral vascular assessment

This assessment is comprised of looking at the pt extremities, determining circulation,mobility and sensation. It is really a meshing of neuro,mobility and musculoskeletal assessment in part, which shows how interrelated our body really is!
I am using PMS Causes Tension as my mneumonic.

P-Pulses. feel the most distal pulse possible on the assigned limbs BILATERALLY because this is a comparative assessment!. If, for instant the person has an amputation below the knee on one side, then you would palpate the popiliteal pulses bilaterally AND the pedal pulse on the remaining limb.A Doppler may be necessary to find pulses on the severely compromised and "may use doppler" will be written on the Kardex. The CE will procure the device.

M- Mobility is assessed by simply asking a person to move the limb or in a young child/non communicative adult, observing spontaneous movement.

S-Sensation.Elicit the pt response to touch of the distal part of the extremity. Ssk them to differential wheather they feel the pressure of the actual touch or numbness ,etc.

C-Color OR Capillary refill to assess perfusion. Squeeze the nail bed and time the color return OR look for paleness,cyanosis,pinkness etc.

T-temperature can be checked when sensation is being tested.

All imformation needs to be accurately recorded bilaterally with a comparison of the extremities.The most common pt who will be assigned this AOC will be the one with a cast/traction or other peripheral vascular impairments.

What other impairments are there you ask?? Well what a great question!!!

There are many , many who are afflicted with either Arterial insufficiency or Venous insufficiency. Defining symptoms and nursing interventions differ , so it is good to be aware of it!

Arterial Insufficiency is when the heart is not getting enough blood TO the legs and the result is coolness, pale skin ,diminished pulses,tingling,decreased sensation, and claudication which is a $5 word for lameness and a gimpy walk. What do we do about this malady??We have the legs in the dependant position as much as possible to help get that blood and oxygen do that compromised tissue and prevent necrosis/tissue death!

Venous Insufficiency is when the blood does not return to the heart in a timely manner.I have heard lay folk call this "pooling". Symptoms include edema,red, itchy skin , pain,normal to slightly war skin temp.The interventions include periods of leg elevation and excercise which will increase the venous return and decrese edema and possible ulceration.

A sample care plan for this AOC may go as follows:

Diagnosis: Ineffective tissue perfusion

Outcome: Pt will identify factoers to increase peripheral circulation ( use this because in the hour or so you are in the room there is no way you will be able to assess improved circulation)

Interventions: Assess the pt knowledge about what causes decreased blood flow to their limbs
Teach Pt ways to improve circulation to extremity.

A diagnosis that goes hand in hand with this is acute pain since so many do have that co morbidity factor.

easy as pie!

Personal Cleanliness

Personal Cleanliness

This AOC will not be co-assigned with Comfort Management as many of the steps are duplicate of each other.This is actually quite simple as long as a few basic rules follow with some common sense.

Provide privacy...noone likes spectators while bathing! pull the curtain/shut the door.
Prevent chilling...the simplest way to do this is to bring a few bath blankets in and cover what is not being washed
Wash, Rinse ,and dry what the patient cannot.
Application of skin prep as assigned. I suspect this will be most likely be for infant bottoms or for someone who is incontinent.

Oral care may be assigned.If you are bringing used emesis basin and toothbrush to them, wear gloves!The CE will indicate what to use for a child under 4 on your Kardex. If the Pt is unable to do this for themselves will be the students area to complete which will give her an excellent chance to inspect mucous membranes.

Bed change may be assigned.The bottom sheet must be tight without wrinkles and the top sheet smooth with the toe area tented so as not to restrict movement. DO NOT shake the sheets out as you open them. That is an infection control issue.We do not want to fling pathogens all over!

If Skin assessment is also assigned this is the perfect time to look them over
A few key notes: Always wash a baby's face BEFORE anything else. This means before you put them in a tub take a washcloth and get their eyes and face.We sure do not want to wash the face with water that has touched their bum!
It used to be standard to change the bath water at least once during the bath. Now they say to change it if it is soapy,dirty or cold.It WILL be one of these things at least once during the bath!!Just do it.
It is likely that your pt is weak and tires easily so gather all your supplies before starting the bath . Keep safety in mind at all times.
this Mneumonic is BOBS
Bathe
Oral Care
Bed linens
Skin Prep
easy as pie!

After a bit I rethought the whole mneumonic and changed it to : BOLT
Bathe (keep warm and private wash ,rinse and dry what they cannot)
Oral care ( wear gloves when picking up that toothbrush and basin!0
Linens
Topical preps ( as assigned , or plain lotion if needed )

Twenty Minute checks

Twenty minute checks

For some reason these twenty minute checks are a source of anxiety for the CPNEr. There are only a few things that NEED to be assessed in the first 20 minutes of implementation.In reality all it takes is a minute to look things over.
I will put the square with the mnumonics the top left on my gridalong with the time 20 minutes from the beginning of implementation . Most of the items on the checks are incorperated in other AOC.

W-wash hands. This must be done BEFORE you commence the implementation phase AND everytime you reenter the room. The only exception is when you spontaneously greet the patient as you enter the room. To do otherwise would be rude and violate OAOC.

I- ID Patient/Introduce your self and the CE. Identify your patient by the wrist band using TWO of the following :Name, DOB,or medical number. I will be introducing myself as a student nurse and the CE as my instructor.

G-Glove.

A-Assess IV site for edema or warmth and for the IV I am assigned be sure the drip rate and or ICD is set properly / Advise the patient that I will be monitering I&O during the time I was there.

A-Ask about pain/pain/Air.In the case of Air this means oxygen flow devices.Be sure the flow meter is set properly.

Skin turgor/Safety/Save tray- Skin turgor is part of checking the hydration level , safety means making sure bed is in low position,call light and slippers are near, Save tray is part of I&O. It would be a shame to have some well meaning staff take the tray away you need.


I am considering using a second set of mnumonics as a double check.
T- Tongue/fontanel

A-air(oxygen)

P-Parenteral

E- Enteral-This includes all fluids, gtubes, bottles etc

D- Drip rates

I-Insertion site

N-Number on ICD

Just Checking all these is not enough. It must be documented on the PCS recording form to count. Do not be suprised if the CE asks to see your form to make sure you have.

Musculoskeletal Management

Musculoskeletal Mangement,long name, simple AOC. As mobility is already an overriding AOC, and you are assessing their balance,posture,equality of movement,assistive devices used and where the patient was moved to and their toleration of the activity.After all of that is done, not much is left to musculoskeletal management.
Think ahead to the type of patient will likely have this AOC assigned. A person in traction, a recent ortho patient,a post CVA or MVA .This will pull togather nicely with an impaired mobility diagnosis.
I will be using JSFASTH :Jump Shots Force Another Score To Happen. I picture a basketball player who has had an injury and needs me to assess and treat him/her.

For the purpose of the PCS, the student will be assigned upper OR lower extremeties to manage.ALL joints of the specified extremity needs to be assessed.For the arms this means shoulders,elbows,wrists,and fingers.The legs include hips,knees,ankles and toes. ALL assessments need to be done and recorded as bilateral as a critical element.

J: joints(bilateral)
S: strength(bilateral)
F: flexability(bilateral)
A: AROM/PROM .The student needs to either direct the pt through range of motion excercises,physically demonstrating on your own body if need be or performing them for FOR the patient supporting the joints. Adduction /Abduction OR Flexion/Extension need to be completed.If there is an affected limb,one side will be done though AROM and one through PROM.
S: supportive/theraputic devices. These can include any splints,CPM machines, immobilizers, positioning tools,and assistive mobility devices.
T: Traction.If the patient has traction, the nurse needs to verify the proper weight of the traction,that lines are hanging freely and unobstructed.Look and adjust the patient so they are in proper alignment and that the position they are in creates counter balance.
H: Heat/Cold if assigned. The type ,location and duration of heat or cold therapy will be indicated on the Kardex.Place a barrier over the skin.Standard is 20 minutes,so as not to injure tissues of the immobilized .Mark the time the treatment is applied as well as when it needs to be removed. Follow through! If you leave the implementaion phase, be sure to report the primary nurse what treatments are still in effect.
As with all management AOC the response of the patient will be assessed and recorded.Before implementation begins, verify the last analgesic dose. ROM will go much smoother if they are comfortable.
Again, this is where that pain assessment comes in with vital signs.Use it to your advantage when planning your care.

Comfort Management

Comfort management is a straight forward AOC. Pt may need assist and care to feel optimal and promote the healing process.Simply the nurse will assess the pt comfort needs by asking them to describe comfort needs or to observe behaviors such as restlessness.If discomfort can be pinpointed to a local site then you perhaps have one of the THREE comfort measures you are required to perform.I have read others indicate that the nurse only needs to offer three, not to actually do them, but that is not what is written in the 12 th edition study guide. If the offered comfort measures are not accepted ASK what you can do for them.
The following are the comfort measures set out by EC:

1)Washing hands, face or other vulnerable skin surfaces. The assist can be simple as providing the warm basin and wash clothes, or washing a baby's bottom at diaper change.

2) Repositions. This has to be done as a required mobility AOC. It is a given !It cannot be turning over and back to the same position.Turning to the side and placing a pillow between the knees is heavan to many.Holding an infant is acceptable repositioning.

3)oral care. if this is done for the pt, you must wear gloves.Even if you are just setting them up to do their own oral care you must wear gloves while bringing supplies.The CE will designate what is being used for peds pt under 4 for oral care.

4)back rub. Yes, this can be time consuming, but it is very appreciated and may incite your pt to be more cooperative. Warm any lotion used and be relaxing, not vigorous with your massage.

5)relaxing/distraction-Tv , a book,a game are suitable for distraction.Relaxation techniques include guided imagery, rhythmic breathing a systematic flexing and releasing of muscles. It can be a bit uneasy to talk someone through it. However if using it to prepare for the CPNE for your own nerves, you have some idea of how effective it can be.

6)Linens. change or straighten

7) Heat/cold as assigned. Use a barrier . Duration, temp, and site will be designated on your kardex .

8) medication ( if assigned) medications that increase comfort are emolliants for skin, throat sprays,topical analgesic, such as bengay.This will be co-assigned under medications on the kardex. Use critical thinking when making up your plan of implementation so that you notice one AOC may converge.

In the end the student nurse must document initial findings, comfort measures instituted and as with all management AOC the pt response to the treatment measures implemented.Try to get a verbal affirmation of improved comfort levels.Observing that a client is asleep or no longer crying especially for a noncommunicative client can be charted.


I made up a Mnumonic or this after a bit" Assess My Humble WORLD reasses which boils down to:Assess Massage Heat/cold,med(all as assigned) Wash ( hands, face,vulnerable) Oral care (wear gloves when picking that stuff up!)Reposition,Linens,Distract/relax, Reassess. I finally can rattle them all off ..yippee

Abdominal Assessment

This assessment must be done IN ORDER to comply with the critical elements for this AOC,otherwise it is a fail.This is not a difficult one at all. I use :P X3IAFM, Pain In Abdomen From Motherhood.

P-pee. Ask the Pt if they need to use the bathroom before you start.It may be quite a distraction to have them exit the bed mid exam when you stimulate the bladder.

P- pain? Ask if the patient to point to , but not touch any areas that have pain or tenderness.

P-Position the pt spine with knees raised. If they have respiratory issues and a lowered head is contraindicated, verbalize CDM and reasons to CE. Provide privacy,expose only the area you need to assess.

I-Inspect-Look at the abdomen from xyphoid process to symphysis pubis, taking note of any contour, scars, dressings,bruising even condition of the umbilicus.Note the appearance of a stoma, if one is present.

A- Auscultate all four quads for bowels sounds, using the dual stethoscope.In order to declare absent bowels sounds , you must listen for a FULL minute. Hyperactive and hypoactive bowel sounds are abnormal findings and ought to be noted, although you will only be scored on being able to distinguish between presence and absence of bowel sounds.TURN SUCTION OFF. Suction will alter bowels sounds.TURN SUCTION ON!

F-Feel abdomen in each quadrant for tenderness or rigidity.Note the Pt reaction while you are doing this. is there any guarding? moaning?grimacing? LIGHTLY (about 1 inch depth) palpate,assessing any areas the pt stated were tender last. You may palpate around a dressing.The dressing does provide a barrier if it is dry, but to be safe I would wear gloves.


M- Measure girth of the abdomen if assign.there may be markers in place where the pt was perviously measured. Standard level is at umbilicus.

R- Record all assessment data collected regarding distention,presence or absence of bowel sounds in the four quads,tenderness or rigidity,abdominal girth (if assigned)

Neurological Assessment

Neuro - anything is about my favorite area of nursing. I will have to be careful not to OVER assess these pt. A typical neuro assessment pt may be post CVA or perhaps a CHI , suspected or otherwise.This is pretty simple and should not cause stress.
Mnuemonic is: AM LPN FR.: AM LPN Forever Records. It reminds me of this neurotic day shift LPN at our facility.

A- Alert?

M- Movement Capable of?Assess the strength equality of contralateral limbs. This is done by asking the pt to grasp and squeeze simultaneously two fingers on each of your hands AND with your hands against the palm of the pt feet ask them to press down. This is the plantar reflex.Observe for equality of movement in children under 3.

L- Level of Conciousness- The pt is asked if they are aware of who,where, and the time of day.This is commonly charted as Alert and oriented X3 or person, place and time. A young child is not able to be assessed in this manner. In this case, age appropriate awareness is substituted,such as recognition of a parent,tracking of lights and interaction with toys.Avoid opinions, look for objective data.A child who is of primary school age may be asked how old they are or where they go to school.

P- Pupils. Using a penlight flash briefly from the outer edge of each eye inward several times while the pt looks upward. Assess for reaction (accomodation),equality.Findings may include sluggishness, a fixed pupil,and inequality of pupil size.

N- Noxious stimulus needed? Noxious stimulus used on an unresponsive pt and the mode should be indicated by the primary nurse. Examples of noxious stimuli are pinching of finger nail beds bilaterally or a sternal rub.

F- Fontenel . This is done on an infant under a year old, with an infant in an UPRIGHT position. A normal anterior fontenel is flat or slightly depressessed. Any other findings are abnormal.

R-Record all data regarding LOC,Fontanel assessment,pupillary response,musculoskeletal observation/equality of motor movemet, noxious stimuli response.

Respiratory Assessment and Respiratory Management

Respiratory Management and Assessment differ by only two steps.To avoid redundancy I will lump them together. Respiratory management and Respiratory Assessment WILL NOT be assigned in the same PCS.
This is probably the most simple Mnumonic I have:PAR for Assessment and PAIR for Management.
As always the compliance with established guidelines is in place.

P- Position the Pt to facilitate respiratory assessment/ hygeine activities. This is usually high fowlers. Invoke CDM if another position is used and cite your reasoning.

A- Assess- breathing pattern, symmetry of chest expansion,nasal flaring or any cough.Auscultate lung sounds,while INSTRUCTING THE PT TO BREATHE AS DEEPLY AS POSSIBLE.You must MOVE THE STETHOSCOPE RIGHT TO LEFT , SIDE TO SIDE when assessing. Listening to one lung then another is NOT acceptable. I would ask for two complete breaths at each location. You must assess upper and lower lungs, but there is nothing to say that you cannot listen in more than 4 places. You should listen near shoulder level( reach with your right hand to the left part of the back as far as you can reach and it ought to be the correct spot) and immediately below the scapula ( imagine the bra line).Do not get specifac when describing lung sounds. normal/abnormal is all you need to know.

I.-Intervene. this is the Respiratory Management distinction. DO NOT start the intervention before the first assessment is complete. That would be a fail.The intervention will be designated. Provide a receptacle for any secretions. If it is a used emesis basis, wear gloves when handing it to the pt and for sure when emptying it!!Usually deep breathing and coughing or incentive spirometry will be assigned. Provide a splint for a pt with recent abdominal surgery. Instruct the pt to take three DEEP breathes and forcefully cough. that counts as one cycle. The CE will write on your assignment Kardex the number of cycles. Inspiromety is a little device that encourages the client to expand their lungs and prevent pneumonia. Chest percussion ,trach care and suctioning may be assigned. If assigned oxygen sat, do not omit!

R-Reassess and record immediately after respiratory hygeine is done and compare to initial documentation.Document pt response to activity.As you assessed bilaterally be sure you chart bilaterally

There is nothing to say you cannot listen to the pt while they are lying on their side or anteriorly but I would be nervous not to at least verbalize a reason for doing anything but posterior.

Wound Management

Wound Management is ofton feared by the student and it should not be. It is one of the lab Simulations and ought to be firm in our minds. There will of course be variations unique to each wound and each pt.
The mneumonic I made up for this is "ACT DR" I think of a nurse finding a wound and inciting the physician to write orders for wound care.
As with all AOC the critical elements start with complying with established guidelines which include pt safety, asepsis, emotional well being,privacy,standard precautions, and promotion . It is a good idea to gather all supplies BEFORE commencing any wound care.The usual supplies include but are not limited to: a water proof bag for disposal of old contaminated dressings,clean gloves, sterile gloves,any topical preparations needed, adhesive tape, the dressing actually needed,sterile scissors,and chux to protect the bed. You may need a gown to protect clothes from a weeping wound. Check the expiration date on any supplies. This assures sterility of the product. Be sure the old dressing is not dragged accross the wound or surrounding skin. This AOC will be treated as a medication administration so IDENTIFY your pt before you begin!!!!!!
A- Assess wound. this is done, of course after the removal and disposal of the old dressing. you will need to observe the qualities of the wound. Location, size, type(puncture, surgical incision,abrasion,decubiti ect) observe the wound bed for color , drainage and any odor. Drainage needs to be accurately described as a change could signal progress or deterioration in a wound.Common drainage types include:seous, sero-sanguinous, purulant or sanguinous. Especially with purulant drainage ,specify color ,viscosity, amount and odor.

C- Cleanse and irrigate. I am putting the two of these together. The dressing order should designate the type of solution for cleansing or irrigation.The usual is room temp solution, but be aware that this may be designated also. If Betadine is ordered, ask the pt if they have an allergy to iodine.This is also a good time to find out if they have an adhesive allergy.Protect the bed and pt from the irrigation return.Observe the characteristics of the irrigation return.Dry off the surrounding skin tissue.

T-topical preps. These are ordered and will be specified on the Kardex. Treat these as you would a medication.


D-Dressing. apply the ordered dressing over the wound.If this is a sterile wound remember to open up all the supplies maintaining sterility and donning sterile gloves.Securely tape your dressing in place. Initial, date and time it as you would in the sim lab.

R- Record. All the information gathered during the wound management needs to be recorded from the wound appearance , irrigation return and pt response.SIGN the MAR!. this is an area many forget. Do not mess up a good dressing change with a flub here!

And you are done! Not so bad is it?

Pain Management

Pain is now seen as the fifth vital sign and needs to be assessed. You will be assigned pain assessment with vitals if you do not get pain managment as a selected AOC,and to be on the safe side I would not ignore a pt complaints of pain even if it is not your AOC, it shows caring to take care of that physiological need. In the very least pain levels should be reported to the primary nurse. The timing depends on the level of pain and pt distress.
My mneumonic is actually dual part memory tool :LAIRD
Here I think of a Scottish underling calling their leige "lord". I certainly would not want my LAIRD in any pain.
L- Level of Pain (PQRST) This is more extensive than the simple number. Look for behaviors especially in a noncommunicative adult or a child like guarding, moaning,curling into a fetal position,clenching hands , restlessness or quivering jaw.
P- Provoking or precipitating factors..what makes it worse?better?does movement make it flare?This gives you an opportunity to understand the pt experience and it may aide you when planning your care
Q- Quality of Pain- Does it shoot? is it sharp? dull? throbbing?
R- Radiation- Does it start in one area and extend to another site?
S- Severity- Use the appropriate scale 0-10 for adults Faces for children
T- Timing- Intermittent, constant ,rare

A- Administers analgesic/Ask primary to medicate. Check the MAR first so you know when the last time your pt was medicated. It is always good practice to ask the pt be med 30 minutes prior to a potentially painful procedure or ambulation, especially if they are post op ortho

I-Intervenes .Only ONE intervention in addition to analgesic is required . Here you would use the information collected in your assessment of pain phase.The pt may already have given you a big hint as to what will work for them.The choices EC gives us are:heat/cold application. This will be assigned along with the method of delivery,time of treatment. Be sure you put a barrier between the heat/cold and the pt.Back massage is always a favorite among people but it can eat up your time so be mindful .Position change have to be done anyways during the PCS and so it is multi tasking.Relaxation/distration can be as easy as putting the TV on or as extensive as guided imagery. be comfortable in whatever you choose.If you are floundering it will be picked up by your pt and be counter productive.

R- Reassess- within 30 minutes of all interventions using the SAME scale.I read of one failing a PCS because the CE thought she used a different scale to reassess.

D- Document -All of the preceding needs to be recorded

Mobility

Mobility is an overriding area of care. What makes it odd is that it is a narrative notre instead of a fill in the blank type that the other OAC are. Mobility needs to be assessed on everyone , is not a difficult task and can easily be incorporation during other cares and is not a timed AOC,having the entire PCS to complete.The pt needs to move to another position at least once during the PCS, moving them to the side and back during cares does not count.The CE will let you know on the assignment sheet if there are any considerations for mobility such as bed rest or may not bear weight or a side they may not lie on. My mneumonic for mobility is BPAEMR : Blood Pressure Always Elicits My Response.
BP- Balance and Posture are simultaneously observed. This is an assessment of the Pt mobility status. Look for any impairment, lack of steadiness , leaning. Include any immobilization such as casts or traction in your assessment.
A- assistive devices/alignment An assistive device is anything used to assist in mobility or positioning. It may be a walker , wheelchair ,pillow,trapeze,a lift, gait belt ,side rails,or a pillow even.Ask yourself if ANYthing assisted this person during movement or positioning.It may be as simple as"Pt assisted to side chair with minimal hands on assist of one"
E - Equality/Extraneous Movements. Observe and Document if the Pt limb movement is symmetrical and if there are any jerking , tremors ect. A client may have hemiplegia that would needs that a person with full use of limbs do not.
M- Moved to. Document where the client was moved to and any assist needed .Be sure to support anything injured or weak.
R- Record/Response. Document all of the critical elements as well as how the client tolerated movement.

Enlist the aid of the CE if needed. Do not attempt any unsafe tranfers or ambulation that may harm you or the client. Be sure you put slippers on the pt who will be gettingout of bed. This pt is your prized possession during your PCS and safety of this fragile treasure is important!!

Oxygen management

Many of the clients in acute care settings will be on oxygen either for direct pulmonary disease process or secondary to decreased respiratory capacity from surgery/pain/etc. The mneumonic I have for this is rather long.
Really Old People's Skin Sag, Find Home Health Records

R - Response to activity. I will be assessing how the patient acts during and immediately after activity. I need to look for shortness of breath a change in pulse or respiratory rate,nostril flaring or use of accessory muscles.
O - oxygenation status.Look at the fingernail beds for the color,any clubbing, and capillary refill. Normal capillary refill is less than 3 seconds ,there should be no clubbing and the nail beds should be pink. Any deviance from normal could be considered an alteration in the oxygenation status, no matter what the cause.
P -Position for optimal oxygenation. This usually means high Fowler's position , with the head of the bed elevated upright. A patient may choose to be in an orthopnic postion,leaning forward ,perhaps resting on pillows on an overbed table. The orthopnic postion is favored by many who have Chronic lung conditions. An overriding area of care is Caring/emotional jeopardy and so you have to take in consideration their preference. I would verbalize to the CE that I advised the patient the optimal postion but due to the patient's desires I would invoke CDM here.
S -Skin assessment. The tubing of oxygen delivery system is unforgiving plastic and can be quite irritating. Check behind ears, in nares and around a face mask. Pad as needed and report skin breakdown to the primary nurse.It is allowed to tape the tubing to the face,but I would be hesitant to do this as tape can be an irritant too.
S - Sats. This is shorts for oxygen saturation. It is a measurement taken by a machine that dispays the O2 level. There is a probe that is attached to a finger or even and ear. Some people are on continuous O2 monitering. If there are parameters to notify the primary , it will be noted on the PCS assignment kardex.
F - Flow rate. This is the amount of flow on the O2 delivery system. If it is by mask, be sure it is the correct one, as this will affect flow rate.Adjust as needed.There may be an order to titrate O2 to keep sats above a certain number.
H -Hazards. Look around for anything that may cause a spark.Remember that oxygen is highly flammable and foremost a safety concern. Remove electric razors.
H - Humidity.Some on higher levels of oxygen flow or long term use use humidity attached to the flowmeter prior to the O2 delivery device. During the PCS keep an eye on it so that it does not run dry or become detached.
R - Records all of the above. Do not leave anything out.Include any change in the patient's condition weather positive or negative.

All together this should not be time consuming and ought to be able to be completed during other assessments and cares.

Enteral feeding

I am going to start with Enteral feeding because I cannot come up with a mneumonic for it and perhaps writing it out will help. One good thing to keep in mind is that personal cleanliness will not be co-assigned with enteral feeding unless it is a continuous feeding(and a heckuva lot less work) First of all Enteral feeding is any nutrition taken into the GI tract. This means a bottle given to a baby, food off a tray or a G-tube,peg-tube, or a naso gastric tube. The first two are pretty basic as they are things we are accostumed to doing all the time. I handle g-tubes at work,but hey this is the CPNE,no room for error right?
The critical elements for enteral feeding are as follows:
1. Complies with established guidelines.This means wash your hands, use gloves if you will be handling ANY body secretions,measure and record!
2.For ALL feedings
a. selects perscribed feeding. This sounds easy ,but in reality there are soooooooooooo many kinds of feeding (with fiber,high nitrogen,high protein), infant formulas,and do not forget this also means giving the right diet to the right patient. Diets are theraputic as medications sometimes.You would not give tiramisu to a diabetic on a 1200 Kcal ADA diet, a hotdog is a no no for a 4 month old,and a puree diet is a must for some.If it a formula,be it for an infant or an adult, make sure it is the right strength. If it is 1/2 stregth then it needs to be diluted with water in equal amounts.ect. INSPECT the label before you open it.make a big show of this and checking the expiration date.
b. position the pt to promote feeding. This means for a tube feeding that the pt ought to be at least at 45 degrees during and immediately after the feeding. An infant out to have its head elevated also. This is to prevent aspiration.TURN OFF the feeding if you need to lower the head of the bed .(usually for cares)
c. deliver the feeding. The CE will designate what route you will use for delivery. This can include but not limited to: A pump,bolus using a 60 ml syringe,gravity,bottle, intermitent or continuous.The CE will also tell you about any flushes post feeding.
3.BURP the infant under 6 months
4. The feeding should be at room temp. I have read studies that it really does not matter as to digestion about the temp of the feeding but follow protocol here.Some facilities "save" feeding from partially used cans to use later in the fridge. I would open fresh and discard what is not needed.
5.For an intermittent TF
a. How MUCH are you to give??be exact. You will have the means to measure.
b.titrate the flow rate . The CE will tell you the drip rate. This is just like titrating an IV.
c.if this is an NG tube`the location will need to be verified. NG tubes are tricky little devils . They are slender slippery things that can curl up and end up at very inconvenient places, like the lungs soooooooooo we will verify it is indeed in the stomach!!by one of the following methods:
1) aspirates stomach acid using a syringe AND checking gastric PH if indicated.Be sure to note amount of residual because there may be parameters for holding a feeding .Reinstill the stomach acid. I have heard some nurses reason that if they discard the excess contents they can proceed with the feeding ,but doing this will cause electrolyte imbalances. OR

2)instilling 10-20 ml of air (5 ml for kids under 2) while auscultating for the "gurgle"
The hospital MAY also have a policy re: Gtubes or j tubes, so unless you are told, ASK.
d.measures residual...regardless of need to check placement.
e.reinstills...be sure to keep the syringe attached or you have to count it as output and intake.
f.you have a 30 minute window in which to give the feeding of its scheduled time...just like a medication.
g. gives feeding at correct rate by either regulating the drip rate or entering the correct number on feeding pump. There is a +/- 5 gtt per minute margian of error.
6.for a continuous feeding:
OK kids this portion is part of the 20 minute checks!! YOU NEED to verify the rate of flow within 20 minutes of implementation phase by either counting the drops per minute of the formula already up OR by documenting the flow rate setting on the feeding pump onto the PCS form...THEN regulate the drops.
You still will need to verify the NG (and perhaps other tubes) at least once during the PCS by the afore mentioned means as well as checking residual (only if indicated for continuous)
7. record everything:amount ,type,strenth,rate,anything pertaining to gastric content as well as how they tolerate it.