OKAY, JUST A LITTLE BIT MORE INFORMATION ON THE VITAMINS.
JUST TO, I DON'T KNOW, KIND OF GET, PULL OUT SOME INFORMATION.
THEY TALK A LITTLE BIT ABOUT CERTAIN VITAMINS BEING ANTIOXIDANTS.
DO YOU UNDERSTAND WHAT ANTIOXIDANTS ARE?
OUR BODY HAS TO BURN OXYGEN AS WELL AS NEED IT TO CREATE THE FUEL
AND SO OXYGEN WE NEED FOR LIFE, BUT IT'S EVENTUALLY GOING TO BE THE THING THAT KILLS US.
IF THAT MAKES ANY SENSE BECAUSE IT'S THE BY-PRODUCT OF OUR METABOLISM.
OXYGEN IN AND OF ITSELF CAN BIND EASILY TO OTHER CHEMICALS
AND OTHER CHEMICALS ISN'T THE WORD I WANT ATOMS.
AND WHEN IT BINDS TO THOSE IT USUALLY SHORTS ONE OF THEM OUT
AND THAT'S WHAT WE CALL A FREE RADICAL. IN OTHER WORDS IT'S AN ATOM THAT HAS AN EXTRA COMPONENT
OR MISSING A COMPONENT TO IT.
AND WHEN THERE'S A FREE RADICAL ROAMING AROUND,
IT'S LOOKING FOR SOMETHING TO EITHER FILL THAT SPACE
OR TO DISCARD THAT PIECE OF THE ATOM.
AND SO IT'S FREE RADICALS THAT CAN BE DAMAGING.
WE ALL HAVE SOME FREE RADICALS WITHIN OUR SYSTEMS.
AND THE FREE RADICALS USUALLY GET NEUTRALIZED FAIRLY SIMPLY IF WE'RE IN A BALANCED STATE.
BUT THE MORE UNBALANCED WE BECOME, THE MORE OXIDATION OCCURS.
THE MOST EASILY OXIDIZED FUEL THAT WE BURN IS CARBOHYDRATES.
SO GLUCOSE OXIDIZES EASILY.
SO OVER TIME IT CREATES AN OXIDIZED STATE IN OUR BODIES
WITH A LOT OF FREE RADICALS WHICH ARE LOOKING TO EITHER DISCARD THAT ATOM
OR TO GAIN AN ATOM.
AND SO IT'S GOING TO TAKE IT FROM OTHER PLACES IN THE BODY TO MAKE IT A WHOLE ATOM.
IN OUR VITAMIN GROUP IN PARTICULAR AND SOME OTHER FOODS,
OUR OMEGA 3'S HAVE ANTIOXIDANT COMPONENTS.
THEY'RE ABLE TO BIND TO AND NEUTRALIZE THOSE FREE RADICALS.
YOU WILL PROBABLY HEAR IF YOU PURSUE NUTRITION AT ALL,
BERRIES ARE A GREAT SOURCE OF ANTIOXIDANTS.
BUT LET'S APPRECIATE HERE WHAT THEY SAY WHEN THEY TALK ABOUT VITAMIN A.
AND I SHOULD HAVE WRITTEN ON THERE IT IS A GOOD ANTIOXIDANT.
VITAMIN E IS A GREAT ANTIOXIDANT AND IF YOU GO ON TO OUR NEXT SLIDE,
IF YOU GO TO MINERALS, SELENIUM.
EVEN IN OUR OWN BODIES, LADIES ARE ESTRADIOL IS A GREAT NATURAL ANTIOXIDANT.
SO YOU'RE GOING TO BEGIN TO APPRECIATE AS WOMEN SHIFT OVER INTO PARAMENAPAUSE
AND INTO MENAPAUSE, IS THEY'RE LOSING ESTRADIOL.
THEY ARE ALSO CREATING A STATE OF OXIDATION
BECAUSE WE'RE NOT CREATING OUR OWN NATURAL ANTIOXIDANT.
SO THEY ALL PLAY TOGETHER, BUT WE CAN SUPPORT OUR SYSTEM
AND THE FUNCTIONING OF OUR BODIES
SO THAT WE'RE MORE EFFICIENT IN OUR USE OF FUEL BY EATING ANTIOXIDANTS.
SO NOTICE A FEW OF THOSE GOOD ANTIOXIDANTS AS YOU'RE LOOKING AT FOOD GROUPS HERE AS WELL.
VITAMIN C IS A GREAT ANTIOXIDANT.
THE AVERAGE DOSE OF VITAMIN C IS 50-100 MILLIGRAMS,
UP TO 6,000 MILLIGRAMS A DAY WHEN SOMEONE IS HAVING RESPIRATORY DISTRESS.
SO YOU CAN TAKE A LOT OF VITAMIN C, BUT IT CAN BE TOXIC.
YOU DON'T WANT TO JUST TAKE TONS AND TONS, AND TONS
AND THINK THIS IS, YOU KNOW, IF A LITTLE IS GOOD MORE IS BETTER.
NOT NECESSARILY TRUE. AND YOU WANT TO WEAN YOURSELF DOWN
IF YOU'VE BEEN TAKING IT FOR A LONG TIME
BECAUSE YOU CAN HAVE SOME ACTUALLY SOME REBOUND OXIDATION IN RESPONSE TO THAT.
VITAMIN K.
HALF OF OUR VITAMIN K COMES FROM INTESTINAL FLORA AND ASSISTS IN CLOTTING.
AND THAT'S WHY WHEN YOU GO TO YOUR NEW BORN NURSERY
AND ALL NEWBORNS GET A SHOT OF VITAMIN K WITHIN THEIR FIRST FEW HOURS OF BIRTH.
I CAN'T REMEMBER WHAT IT IS EXACTLY,
BUT IT'S BECAUSE THE INTESTINE ISN'T DEVELOPED WELL ENOUGH YET
AND WE NEED THE VITAMIN K ONBOARD SO THAT THEY DON'T BLEED OUT.
IT HELPS WITH THE CLOTTING.
WE GET THE OTHER FROM FOOD SOURCES.
SO HALF FROM THE INTESTINE AND HALF FROM DIET.
THAT'S WHY IF YOU HAVE DIARRHEA, WHAT DO YOU LOOSE A LOT OF?
K. BECAUSE IT'S DEPLETED THROUGH THE VALVE.
VITAMIN B AND C ARE YOUR WATER SOLUBLE VITAMINS.
B-COMPLEX OFTEN REFERRED TO AS STRESS VITAMINS
HELP WITH SKIN, CRACKED LIPS, HYPOLIPODEMIA, NEURITIS AND SO FORTH.
AND YOU CAN READ ABOUT THEM.
I THINK VITAMIN B'S ARE INTERESTING.
DON'T YOU THINK THEY SHOULD HAVE B NAMES INSTEAD OF NIACIN, RIBOFLAVIN AND THIRODOXIN?
I DON'T KNOW. IT'S LIKE I ALWAYS HAVE TO THINK, "WHAT IS THAT?" WHEN THEY SAY IT.
IT'S VITAMIN B. "WHY DON'T YOU JUST SAY SO?"
THEY DON'T KIND OF MATCH MY VISUAL MIND OF TRYING TO MAKE THOSE MAKE SENSE.
BUT THIAMIN IS YOUR B1, AND RIBOFLAVIN B2, AND NIACIN B3, THIRODOXIN B6.
B12 IS ONE I ELUDED TO BEING STORED INTO THE LIVER FOR UP TO TWO TO THREE YEARS
BEING ESSENTIAL FOR DNA SYNTHESIS.
SO IT HAS A LOT TO DO WITH JUST DNA, BODY BUILDING, BLOOD CELL FORMATION AND SO FORTH.
I DIDN'T MAKE A SLIDE ON FOLIC ACID.
I MEAN YOU CAN TALK EXHAUSTIVELY ABOUT SOME OF THESE,
BUT JUST SUFFICES TO SAY THAT FOLIC ACID IS ESSENTIAL FOR BODY GROWTH AND DNA SYNTHESIS.
AND A DEFICIENCY IN THE FIRST TRIMESTER OF A PREGNANCY CAN AFFECT THE CNS OF THE FETUS.
AND SO THAT'S WHY YOU WILL SPEND A LOT MORE TIME TALKING ABOUT FOLIC ACID,
BUT WHY IT'S IN ALL PRENATAL VITAMINS
BECAUSE IT'S SO ESSENTIAL IN THAT FIRST TRIMESTER,
SO THAT THE CNS OF THE FETUS DEVELOPS APPROPRIATELY.
YOU NEED 400 MICROGRAMS OF FOLIC ACID PER DAY.
MINERALS ARE CERTAINLY IMPORTANT.
WE HAVE INORGANIC OUT THERE, INORGANIC ELEMENTS ESSENTIAL TO THE CATALYSTS
AND BIO-CHEMICAL REACTIONS.
THEY ARE ESSENTIAL TO METABOLISM.
THERE IS MACRO-MINERALS AND MICRO-MINERALS.
MACRO-MINERALS ARE MINERALS THAT YOU NEED MORE THAN 100 MILLIGRAMS PER DAY OF.
AND MICRO-MINERALS ARE LESS THAN A 100 MILLIGRAMS PER DAY.
IRON CAN FALL INTO THE GROUP OF MACRO-MINERALS.
WE SUPPLEMENT UP TO 325 MILLIGRAMS IN MANY OF OUR TABS.
WE GET ABOUT FIVE TO TWENTY MILLIGRAMS PER DAY IN DIET, SO.
BUT WE NEED A LITTLE BIT MORE THAN THAT.
IRON HELPS WITH HEMOGLOBIN, LIVER IT'S FOUND IN LIVER,
LEAN MEATS, DRIED BEANS, GREEN VEGETABLES.
AND IRON IS BEST TAKEN WITH VITAMIN C.
IT FACILITATES THE ABSORPTION OF THAT.
SO THOSE TWO NEED TO BE TAKEN IN COMBINATION.
COPPER, ZINC, CHROMIUM, AND SELENIUM ARE USUALLY CONSIDERED YOUR MICRO-MINERALS
FOUND IN VARIOUS SHELL FISHES AND FOODS.
CHROMIUM IS AN INTERESTING MINERAL THAT THEY'RE HAVING TO HELP BALANCE BLOOD SUGAR
AND HELP WITH METABOLISM IN THE BODY.
AND SELENIUM BEING AN IMPORTANT ANTIOXIDANT IN MEATS AND SEAFOOD.
WHEN YOU'RE TAKING YOUR IRON, INTERESTINGLY, AND IT MAKES SENSE,
BUT ANTACIDS DECREASE THE ABILITY OF IRON BEING ABLE TO ABSORB.
SO YOU DON'T TAKE IRON WITH ANTACIDS,
BUT YOU DO TAKE IT WITH VITAMIN C TO FACILITATE THE ABSORPTION.
I'M NOT GOING TO SPEND A LOT OF TIME HERE BECAUSE THIS WAS ALL QUITE CLEAR IN YOUR BOOK.
BUT DO SPEND SOME TIME.
I DID ASK SOME QUESTIONS ABOUT DIETS RELATED TO CERTAIN BELIEF SYSTEMS
OR RELIGIOUS PRACTICES, ETHNICITIES, AND BE AWARE OF THAT.
IN PARTICULAR...SEVENTH-DAY ADVENTISTS, AVOID MILK.
HAVE YOU EVER GONE AND EATEN AT THE SEVENTH DAY ADVENTISTS HOSPITAL?
- YEAH. - THAT WAS KIND OF AN INTERESTING TIME.
- NO MUSTARD. - UH-HUH.
YEAH. THE FIRST TIME WAS SEASONINGS AND NO MEATS AT ALL.
SO THEY AVOID PORK, SHELLFISH, ALCOHOL.
HIGHLY VEGETARIAN.
LOOK AT WHEN YOU'RE LOOKING AT DIETS, COMPARE WHAT'S SAME,
BUT THEN IDENTIFY WHAT'S DIFFERENT.
IT'S MUCH EASIER TO FIGURE OUT WHAT'S DIFFERENT IN SOME OF THESE FOOD GROUPS.
JUDAISM AVOIDS PORK AND SHELLFISH, PREDATORY FOOD.
THEY DON'T MIX MEATS AND DAIRY AND CELEBRATE YOM KIPPUR.
CATHOLICS WEREN'T ON THE LIST IN THE BOOK.
WASN'T THAT SURPRISING?
I MEAN, CATHOLICISM IS PRETTY PROMINENT IN OUR SOCIETY.
AND SO THE LAST GROUP I TAUGHT AND I SAID, "YOU GUYS STILL DON'T EAT FISH ON FRIDAY'S?"
I MEAN THOSE ARE I THOUGHT THAT WAS KIND OF UNUSUAL THAT THAT WASN'T ON THERE.
BUT ANYTHING ELSE PARTICULAR RELATED TO CATHOLICISM?
- LENT. - LENT.
WHEN IS THAT FROM? SOMETHING TILL EASTER.
HOW LONG BEFORE? - ASH WEDNESDAY.
VEGETARIAN DIETS THOSE ARE ALL PERFECTLY EXPLAINABLE.
OVOLACTOVEGETARIAN, EAT EGGS AND THEY EAT MILK AND LACTO AND THEY GET NOTHING.
FRUITITARIAN, THAT WAS THE ONE THAT REALLY SURPRISED ME.
I NEVER HEARD OF A FRUITITARIAN TILL I READ THIS BOOK.
AND I WENT, "WOW."
COULD YOU LIVE ON ALMONDS AND HONEY FOR THE REST OF YOUR LIFE?
I DON'T KNOW. IT SEEMS LIKE IT WILL BE A LITTLE DEFICIENT THERE. PRETTY BAD, SO.
THE MAIN THING ABOUT SPECIALTY DIETS --
IS THAT AGAIN WE'RE TRYING TO LOOK TO SEE IF THEY ARE GETTING THE COMPONENTS THAT ONE,
BALANCE THE INSULIN/GLUCAGON RATIO.
BECAUSE ALL BODIES NEED FAT AND SUGAR. THE BRAIN NEED IT IT DOESN'T MATTER WHO YOU ARE.
SO ARE YOU ABLE TO MEET THAT WITH YOUR DIET PREFERENCE THAT'S BEEN CHOSEN.
AND SOME OF THEM BECOME QUITE THE CHALLENGE.
AND ESPECIALLY SOME OF THESE VEGETARIAN DIETS BECAUSE THE SOURCE OF PROTEIN --
YOU NEED TO GET ENOUGH OF IT TO MEET THAT REQUIREMENT THERE FOR THE DAY.
SO REVIEW THOSE AND THEY CERTAINLY MAKE SENSE.
WE'VE TALKED ABOUT ALL THESE DIETS, SO JUST LOOK AT IN THE BOOK.
BUT I JUST WANTED YOU TO LOOK AT IT EVEN SOME MORE THINGS THAT I HADN'T MENTIONED
WHEN WE WERE TALKING ABOUT IRON.
THERE ARE A LOT OF DIETS OUT THERE THAT HELP OUT PATIENTS
AND WE'RE GOING TO TALK ABOUT SOME DIFFERENT DIAGNOSIS HERE IF WE GET TO 'EM TODAY
AND WHEN THESE DIETS WOULD FALL IN.
THINGS YOU WANT TO ASSESS THAT ARE RELATED TO DIETS ARE WHAT IS SOMEONE'S NORMAL INTAKE
AND PATTERN OF EATING.
I WAS TALKING TO A GUY YESTERDAY AND HE ONLY EAT TWO MEALS A DAY
AND I'VE DONE IT FOR YEARS AND I GUESS THAT'S JUST WHAT MY BODY NEEDS.
AND I'M THINKING, " IT'S PROBABLY WHAT YOUR BODY IS USED TO, NOT WHAT YOUR BODY NEEDS."
WE NEED MORE FUEL AND FOOD EVENLY SPACED THROUGH OUT THE DAY.
BUT FIND OUT WHAT THEIR PATTERN IS,
WHAT KIND OF SYMPTOMS THEY'RE EXPERIENCING.
IS IT A FOOD RELATED SYMPTOM?
ALLERGIES CAN BE RELATED TO FOOD OR THE ABSENCE OF FOOD.
THEY FOUND THAT IF WE GET HOMEOSTASIS IN OUR BODIES
AND GET A BETTER BALANCE OF OUR OMEGA3'S
THAT SOME OF THOSE ALLERGIES TEND TO DISSIPATE
AND SO IT'S QUITE FASCINATING HOW TO MANGE SOME OF THAT STUFF WITH JUST DIET.
TASTE. ELDERLY LOOSE A SENSE OF TASTE.
WELL, THEN THEY DON'T EAT. I WOULDN'T EAT THAT MUCH IF IT DIDN'T TASTE GOOD.
I NEED IT TO TASTE GOOD, LIKE YOU KNOW IT FEELS GOOD.
SO WHAT'S GOING ON WITH THEM? ARE THEY ABLE TO CHEW? ARE THEY ABLE TO SWALLOW?
TAKING CARE OF PATIENTS, LOST THEIR DENTURES, THEY'VE BEEN GUMMING IT FOR A LONG TIME.
WELL, IF THEY DON'T TELL SOMEONE, DIETARY SENDS A NICE, CHEWY PIECE OF STEAK,
THEY'RE OUT, THEY'RE NOT GOING TO BE ABLE TO GET THAT DOWN.
SO BE CONSCIENCE ABOUT WHAT'S GOING ON WITH YOUR CLIENT.
HOW THEIR APPETITE IS? ANY CHANGES IN ANY OF THESE THINGS,
APPETITE, ELIMINATION AND ANY MEDICATION THEY'RE ON.
REMEMBER THAT - WHEN WE'RE TALKING ABOUT DIET AND METABOLISM
IT'S FROM HERE TO HERE. IT'S THAT WHOLE BIG ALIMENTARY CANAL, IF YOU WILL, TRACT,
THAT AFFECTS ARE DIET, SO A LITTLE HISTORY IS IMPORTANT.
THINGS THAT WE DO TO ASSESS IN ADDITION TO HISTORY IS ANTHROPOMETRY.
WHAT'S THAT? YOU REMEMBER?
IT'S WEIGHING -- IT'S BODY MEASUREMENTS. AND SO IT'S WEIGHING BODY PARTS, BONES
AND SO LOOKING AT THAT.
BUT FOR US IT'S BODY WEIGHT, I&O,
SO THAT WE'RE GETTING A GOOD SENSE OF WHERE THAT CLIENT IS.
BODY MASS INDEX. HOW DO YOU KNOW WHETHER YOU FALL WITHIN AN ACCEPTABLE WEIGHT FOR YOUR AGE
AND YOUR HEIGHT?
YOU SEE THOSE CHARTS ALL THE TIME.
BUT WHAT THEY'VE DONE NOW FOR US IS THEY'VE GIVEN US A BODY MASS INDEX.
AND SO WHAT YOUR SUPPOSE TO DO NOW IS, MULTIPLY YOUR POUND WEIGHT , GOT IT, TIMES 703.
WHATEVER YOU WEIGH IN POUNDS TIMES 703. DIVIDE THAT BY YOUR HEIGHT IN INCHES SQUARED.
THAT'S AN INTERESTING ONE. I'LL SHOW YOU HOW TO DO IT HERE IN A MINUTE.
AND THEN WHATEVER THAT IS IS YOUR BMI.
IF YOUR LESS THAN 25 YOUR HEALTHY.
IF YOUR BETWEEN 25 AND 30, YOUR HIGH RISK.
AND IF YOUR GREATER THAN 30 YOUR CONSIDERED OBESE OR THEY ARE. LET'S NOT MAKE IT PERSONAL HERE TODAY.
AND YOU HAVE AN INCREASED RISK OF CORONARY ARTERY DISEASE.
SO JUST SQUARE YOUR -- I WAS LOOKING, I JUST FIGURED OUT MY OWN HERE.
SO MY WEIGHT TIMES 703 GOT ME A NUMBER.
DIVIDED BY MY HEIGHT IN INCHES SQUARE, THAT'S MULTIPLYING IT TO ITSELF.
SO I'M 63.5 INCHES SO I MULTIPLIED63.6 X 63.5 TO GET MY WHOPPING 4000.
SO THE NUMBER YOU GET TIMES MY WEIGHT TIMES 703 IS DIVIDED BY YOUR HEIGHT SQUARE.
SO JUST MULTIPLY YOUR HEIGHT IN INCHES TO EACH OTHER AND THAT WILL GIVE YOU YOUR NUMBER.
let's GO QUICKLY. NURSING DIAGNOSES. LET'S JUST PASS THERE.
IDEAL BODY WEIGHT IS ON THOSE CHARTS.
WHAT IS IDEAL FOR YOUR HEIGHT AND YOUR AGE?
LABORATORY TESTS GIVES US SOME GOOD INDICATIONS IF OUR CLIENT IS WITH THEIR DIET.
IN PARTICULAR, WHAT?
LAB. ALBUMIN. LOVE THAT ALBUMIN.
PREALBUMIN AND ALBUMIN. PREALBUMIN IS USUALLY WHAT WE GET FOR ACUTE ILLNESS
TO SEE WHERE THERE ALBUMIN IS. AND ALBUMIN IS FOR A CHRONIC STATE
TO SEE WHAT GOING ON WITH THAT CLIENT.
H AND H IS ALWAYS AND IMPORTANT MEASURE RELATED TO A CLIENTS NUTRITIONAL STATUS.
AND THEN CERTAINLY NITROGEN (PUN).
CLINICAL OBSERVATIONS AND EXPECTATIONS.
OOPS. PAST THROUGH HERE.
LET'S HAVE A LOOK. PAST THREE.
SO NURSING DIAGNOSES THAT RELATE TO NUTRITION.
THINGS TO BE THINKING ABOUT, IS THERE RISK FOR ASPIRATION.
SO IT'S NOT A NATURAL PROBLEM IT'S CERTAINLY AT RISK PROBLEM.
CONSTIPATION IS A NUTRITION PROBLEM.
SO NUTRITION WILL BE CONSTIPATION, DIARRHEA,
MAYBE IMBALANCE NUTRITION. LESS THAN BODY REQUIREMENTS OR MORE THAN BODY REQUIREMENTS.
AND EVEN FEEDING, A SELF-CARE DEFICIT,
UNABLE TO FEED THEMSELVES.
SO JUST SOME THINGS THAT YOU MIGHT WANT TO CONSIDER.
SOME GOALS WOULD BE CLIENTS DAILY NUTRITIONAL INTAKE MEETS THE MINIMUM DRI.
WHICH IS THE DIETARY REFERENCE INTAKE.
AND THAT'S THE CRITERIA THAT THEY SET UP FOR US AS TO HOW MUCH WE SHOULD HAVE PER DAY.
SO THAT WOULD BE REASONABLE. THAT'S GLOBAL THAT WE MEET THAT MINIMUM REQUIREMENT.
IF IT WAS GOING TO BE AN OUTCOME IT WOULD NEED TO SAY, EXACTLY WHATWE WANTE D THEM TO REACH BY WHEN.
SO, PATIENT WILL EAT 1500 CALORIES WITHIN 48 HOURS.
PATIENT WILL EAT OF ALL FOUR FOOD GROUPS OR -- SO YOU BE MORE SPECIFIC.
PATIENT WILL EAT FIVE MEALS A DAY AND SO ON AND SO FORTH.
CLIENT WILL HALF A POUND PER WEEK.
THAT'S MEASURABLE. THAT'S GOT A TIME FRAME.
SO EVERY WEEK ON MONDAY -- YOU MIGHT EVEN SET A DATE THAT WOULD EVEN BE BETTER.
ON MONDAYS, PATIENT WILL BE WEIGHED.
SET PRIORITIES AND CONTINUITY OF CARE.
PLANNING AND THEN IMPLEMENT.
IMPLEMENTATION I'M NOT GOING TO SPEND A LOT OF TIME ON. YOU CAN READ OVER THE SLIDE.
BUT WE WANT TO EDUCATE OUR CLIENTS THEIR IS SO MUCH TO LEARN.
I COULD TALK FOR HOURS AND HOURS ON DIET. THERE ARE BOOKS AND BOOKS ABOUT DIET.
THERE IS SO MUCH TO LEARN SO HONING IN ON WHAT THE CLIENT NEEDS AND WHAT'S PERTINENT TO THEM IS REALLY IMPORTANT.
HELPING THEM PLAN THEIR MEALS. THE TRUTH OF THE MATTER IS NOBODY EATS LIKE YOU.
NOBODY EATS LIKE ME. SO JUST ASSUMING
THAT I CAN PULL OFF WHAT I DO WITH SOMEONE ELSE, ISN'T FAIR.
WE'VE GOT TO FIND OUT WHAT THEIR FOOD PREFERENCES ARE,
THERE SCHEDULE AND SO FORTH TO WORK WITH THEM.
AND IT TAKES A LOT OF TIME AND THAT'S WHY WE USUALLY REFER TO DIETITIANS
COS WE DON'T HAVE THAT AMOUNT OF TIME IN ACUTE CARE.
BUT RECOGNIZING IT AND HELPING THEM WORK THROUGH THAT.
I DID PUT THIS LIST OF FOOD STORAGE AND PREPERATION SAFETY ISSUES DOWN.
WE TALK SOME ABOUT IT WHEN WE TALKED ABOUT SAFETY, BUT JUST APPRECIATE THAT BOTULISM
IS FROM IMPROPERLY HOME-CANNED AND SMOKED FOODS.
E. COLI AND THIS IS WHAT WE'RE FAMILIAR WITH IN OUR VALLEY.
I CUT OUT ALL THE ARTICLES WHEN WE WERE GOING THROUGH THAT BIG E. COLI SCARE. VERY INTERESTING.
WE GET IT FROM UNDERCOOKED MEATS, UNWASHED FOODS
AND YOU GET IT FROM THE SOIL,
FROM WORKERS, FECAL MATERIAL, WATER, FROM IRRIGATION.
WASN'T THAT WHERE THEY EVENTUALLY FOUND THE PROBLEM
WHEN WE HAD THE BIG SPINACH ORDEAL.
THEY ALSO WERE CHECKING THE EQUIPMENT. TO SE IF THE EQUIPMENT WAS CLEAN.
IF IT WAS SOMETHING TO DO WITH THE PROCESSING OR IT WAS SOMETHING TO DO WITH IRRIGATION,
YOU KNOW, OR MANURE OR WHATEVER THEY WERE DOING.
AND CERTAINLY MAKING SURE THE MEATS ARE COOKED.
PORRINGERS ENTERITIS IS MEAT DISHES HELD AT ROOM TEMPERATURE OR WARM TEMPERATURE.
AND THE RECOMMENDATION IS WE DON'T EAT ANYTHING
OR KEEP ANYTHING OUT MORE THAN TWO HOURS.
SO AGAIN WATCH THOSE POT LUCKS.
STAY AWAY FROM THE POTATO SALAD.
SALMONELLEA, MILK, CUSTARD, EGG DISHES.
SHIGELLA IS MILK PRODUCTS AS WELL.
AND THEN STAFF IS IN CUSTARDS TOMATO SALADS AND CASSEROLES.
SO YOU CAN BEGIN TO SEE YOUR MILK PRODUCTS CATCH A LOT OF THOSE...AS WELL.
IMPLEMENTATION OF CARE IS ADVANCING DIETS APPROPRIATELY, PROMOTING APPETITE,
ASSISTING WITH FEEDING, ESPECIALLY WITH RISK FOR ASPIRATION CLIENTS.
AND ONE OF THE THINGS YOU WANT TO BE REALLY CAREFUL ABOUT IF YOUR FEEDING A CLIENT
IS GET THE HEAD OF THE BED UP AS FAR A POSSIBLE
GET THEM SET UP TAKE THE SIZE BITE THAT THEY CAN HANDLE.
IF THEY ARE STROKE, YOU FEED THEM INTO THEIR STRONG SIDE,
FEED SLOW ENOUGH, MAKE SURE IT'S NOT TOO HOT.
TRY TO KEEP IN COMMUNICATION WITH YOUR PATIENT
AND BE CAREFUL ABOUT THOSE THAT ARE FOR RISK FOR ASPIRATING.
RISK FOR ASPIRATION YOU NEED TO BE CONSCIENCE THICKER FOODS AND HAVE NECTAR THICK FOODS.
ARE YOU FAMILIAR WITH THAT PHRASE A LOT IN YOUR HOSPITALS?
SO BE USING THINGS THAT ARE THICK.
WATERED DOWN NECTAR THICK DOES NOT HELP THAT PERSON SWALLOW BETTER.
THINNER FOODS ARE HARDER TO SWALLOW AND IT'S EASIER TO ASPIRATE.
YOU SHOULD NOT USE STRAWS. THEY SUCK TOO MUCH AIR AND THEY CAN ASPIRATE AS WELL.
SO AVOID STRAWS WHEN ASPIRATION IS AT IT'S POTENTIAL.
ALLOW MORE CHEWING TIME WHEN YOUR FEEDING SOMEONE.
UNLESS THEY JUST SAY, "FEED IT FASTER." I'VE HAD PEOPLE TELL ME.
I LIKE TO EAT FASTER. I KIND OF INHALE MY FOOD
SO THAT WOULD JUST MAKE ME CRAZY IF THEY MADE ME WAIT 2 OR 3 MINUTES BETWEEN EVERY BITE.
SO BE CONSCIENCE ABOUT HELPS THEM.
FOR SOMEONE THAT'S BLIND, THEY CAN BE INDEPENDENT.
DON'T THINK JUST COS THEY'RE BLIND, YOU HAVE TO FEED 'EM.
SET UP THEIR TRAY OF A PLATE LIKE A CLOCK. I'VE PUT YOUR CHICKEN AT 12 O'CLOCK.
I'VE PUT YOUR GREEN BEANS AT 3 O'CLOCK. CAN I PUT YOUR PUDDING AT 8 O'CLOCK?
AND YOUR MILK CARTON IS ABOVE YOUR PLATE AT 2 O'CLOCK.
AND EXPLAIN WHERE THINGS ARE AND THEY'RE USUALLY QUITE CAPABLE OF DOING IT THEMSELVES.
SO IF THEY NEED HELP CUTTING OR WHATEVER YOU CAN DO AS APPROPRIATE.
ALRIGHT.
QUESTIONS.
THE CLINICAL NURSE INSTRUCTS AN ADOLESCENT
WITH IRON DEFICIENCY ANEMIA ABOUT THE ADMINISTRATION OF ORAL IRON PREPARATION.
THE NURSE WILL INSTRUCT THE ADOLESCENT TO TAKE THE IRON WITH...?
SO WE HAVE OUR STORY.
THAT IS THE CASE SCENARIO, THAT FIRST SENTENCE.
THE SECOND, THE STEM OF THE QUESTION IS WHAT DO YOU TAKE IRON WITH?
- DO YOU REMEMBER? - VITAMIN C.
- VITAMIN C. SO LET'S LOOK AND SEE WHAT OUT ANSWERS ARE.
WATER. MILK. TOMATO JUICE. APPLE JUICE.
THIS IS HIGH-LEVEL QUESTION
BECAUSE YOU HAVE TO ANALYZE TO SEE WHICH OF THOSE PRODUCTS
YOU BELIEVE HAS THE MOST VITAMIN C IN IT.
WOULD BE MILK? NO. WOULD IT BE WATER? NO.
TOMATO JUICE AND APPLE JUICE,
OF THOSE TWO PRODUCTS WHICH ONE HAS THE MOST C?
- TOMATO JUICE. - TOMATO JUICE.
SO THE ANSWER IS TOMATO JUICE.
AND THAT PUSHES YOU BEYOND. AND THAT'S THE KIND OF QUESTION YOU'LL SEE IN INCLEX.
I HAVE A COUPLE OF THOSE ON THE TEST.
JUST BE AWARE OF WHICH FOOD MEETS THE CRITERIA OF THIS.
ALRIGHT, THE NURSE IS DEVELOPING A PLAN AND CARE FOR HER CLIENT WITH A HIP SPICA CAST,
IN HER PLANNING THE NURSE PLANS TO LIMIT COMPLICATIONS OF PROLONGED IMMOBILITY
THE ESSENTIAL PART OF THE CLIENTS PLAN AND CARE IS TO...?
WHAT'S THE STORY?
WHAT'S THE CASE SCENARIO?
IMMOBILE. RIGHT?
WHAT'S A HIP SPICA CAST?
IT'S A BIG OLD CAST THAT COME DOWN TO THEIR LEGS AND THERE IS THE LITTLE BAR IN BETWEEN.
AND IT COMES ALL THE WAY FROM HIP TO LEG.
YOU SEE 'EM IN KIDS SOMETIMES WHEN THEY FALL AND BREAK A LEG, OK?
SO THEY'RE IMMOBILE. THEY'RE IN A CAST
THEIR WHOLE SELF IS IMMOBILIZED.
SO WHAT'S IMPORTANT? WHAT'S THE STEM OF THE QUESTION?
WE HAVE NO IDEA?
THIS COULD BE THERAPEUTIC COMMUNICATION. THIS COULD BE SOMETHING TO DO WITH MOBILITY.
IT COULD BE WITH DIET COS THAT'S WHAT WE'RE STUDYING.
SO PROVIDE A DAILY FLUID INTAKE OF 1000 ML 24 HOURS.
WHAT DO YOU THINK ABOUT THAT?
IT'S NOT ENOUGH FOR 24 HOURS, RIGHT?
SHOULD IT BE 2000? WE DON'T HAVE ANYTHING BETTER RIGHT NOW,
BUT WE DON'T THINK THAT'S ENOUGH.
MONITOR FOR SIGNS OF LOW SERUM CALCIUM.
I DON'T KNOW WHAT TO THINK ABOUT THAT ONE.
MAINTAIN THE CLIENT IN A SUPINE POSITION.
WELL, OF COURSE NOT, RIGHT?
WE'RE NOT GOING TO JUST LEAVE THEM ON THEIR BACKS.
WE CAN GET RID OF ONE AND TOW SO FAR. I MEAN 1 AND 3. I DON'T KNOW WHAT TO DO WITH 2.
AND FOUR, LIMIT MILK AND MILK PRODUCTS TO MEALS ONLY.
WHAT THE HECK?
HIGH LEVEL QUESTION.
NOW, ONCE YOU GO BACK TO IMMOBILITY, WHAT HAPPENS WHEN A CLIENT IS IMMOBILE?
SPENT QUITE A BIT OF TIME TALKING ABOUT SOMETHING WITH METABOLISM.
YOU REMEMBER?
CALCIUM.
YOU DON'T REMEMBER.
THAT'S WHY I PUT THE QUESTION. NOT BECAUSE I -- ANYONE?
OKAY. CALCIUM RESORPTION.
DOES CALCIUM ABSORB WHEN YOUR IMMOBILE?
NO. WHAT DOES THE BONE DO?
IT RELEASES CALCIUM.
SO IF SOMEBODY IS IMMOBILE ARE THEY ARE RISK?
DO WE NEED TO MONITOR FOR LOW SERUM CALCIUM?
WHAT ARE THEY AT RISK FOR?
HIGH SERUM BECAUSE THE BONE IS NOT ABSORBING CALCIUM, IT'S RESORPTING.
IT'S RELEASING CALCIUM INTO THE BLOOD.
SO WE'RE NOT GOING TO MONITOR FOR LOW BECAUSE IT'S GOING TO BE HIGH.
ANSWER. LIMIT MILK AND MILK PRODUCTS. WHY?
BECAUSE THEY ALREADY HAVE A HIGH CALCIUM LEVEL. WE DON'T WANT TO BE LOADING UP MORE.
YOU WITH ME THERE? SO YOU HAD ENOUGH INFORMATION. HIGH-LEVEL QUESTION.
BUT NOW YOU KNOW HOW TO RETHINK THAT THROUGH.
ELIMINATE WHAT YOU KNOW IS OBVIOUS
AND SEE IF YOU CAN THINK THROUGH LOGICALLY WHAT EACH OF THOSE OTHER ANSWERS ARE.
AND IT IS NUMBER 4.
ALRIGHT AND FINALLY.
THE CLIENT HAS TO BE DISCHARGED ON WARFARIN COUMADIN THERAPY.
WHAT IS COUMADIN?
BLOOD THINNER. WE HAVEN'T TALKED A LOT ABOUT IT, JUST A LITTLE.
BUT WE KNOW IT'S THE ORAL FORM OF BLOOD THINNING.
WHICH STATEMENT BY THE CLIENT WOULD INDICATE THAT FURTHER TEACHING IS NEEDED?
SO WHAT DOES THAT MEAN?
THE STEM IS THEY'RE ON CUMADIN. I MEAN THE CASE SCENARIO.
BUT THE STEM IS WE DON'T KNOW. BUT FURTHER TEACHING MEANS SOMETHING IS WRONG.
SO ANYTHING THAT'S COMPLETELY RIGHT IN THE ANSWER. WE'RE KEEPING.
AND IF IT'S WRONG THEY NEED FURTHER TEACHING.
YOU MAKE SURE YOU'RE FOCUSED THE RIGHT WAY.
THIS MEDICINE THINS MY BLOOD AND ALLOWS ME TO CLOT SLOWER.
I LIKE THAT.
"I NEED TO HAVE A PROTHROMBIN TIME CHECKED IN 2 WEEKS."
AND YOU'RE GOING TO SAY TO YOURSELVES. PT, I KNOW SHE TOLD US THAT.
PT AND PTT. HEPARIN. TWO T'S.
PT, WARFARIN. PT BOAT GOES TO WAR SO THAT'S RIGHT.
"IF I NOTICE ANY INCREASED BLEEDING OR BRUISING. I NEED TO CALL MY DOCTOR."
BIG, "SO?"
I MEAN, REALLY, THE ONLY THING MAYBE YOU'RE, KIND OF, THINKING IS,
"SHOULD HE CHECK IT IN TWO WEEKS OR ONE WEEK OR WHAT?"
SO IF YOU'RE NOT SURE, MAYBE YOU COULD BE LOOKING AT TWO.
LET'S WHAT FOUR IS.
"I NEED TO INCREASE FOODS HIGH IN VITAMIN K IN MY DIET."
WHAT DO WE KNOW ABOUT VITAMIN K?
INCREASES CLOTTING AND WE'RE TRYING TO THIN BLOOD.
SO WHETHER IT'S CHECK YOUR BLOOD IN TWO WEEKS OR A MONTH WE DON'T KNOW.
WE KNOW THIS IS REALLY WRONG.
SO BEST ANSWER NUMBER 4.
OKAY. AND THAT'S KIND OF A WAY TO WORK WITH ON A HIGHER LEVEL,
APPLICATION ANALYSIS TYPE LEVEL QUESTION.
WHAT ARE GOING TO DO WITH THE INFORMATION YOU JUST READ.
HOW DO YOU APPLY IT IN YOUR ENVIRONMENT.
ALRIGHT. WE'RE GOING TO TRY AND CLIP ALONG HERE. AND GET INTO ENTERAL FEEDINGS.
IT'S ONE THING TO BE ABLE TO EAT THE FOOD THAT'S PUT BEFORE YOU,
BUT WHEN YOU CAN'T EAT HOW DO WE GET THOSE NUTRIENTS THAT WE KNOW CLIENTS NEED TO THEM.
AND WE DO IT BY ENTERAL FEEDINGS.
AND AN ENTERAL FEEDING IS WHEN WE PUT A TUBE INTO THE ALIMENTARY TRACT
BY ONE METHOD OR ANOTHER TO GET THE FOOD TO THEM.
YOU'RE GOING TO BE PUTTING NASOGASTRIC TUBES DOWN
AND WE'LL TEACH YOU ABOUT SOME G TUBES IN A COUPLE WEEKS.
BUT RIGHT NOW I'M JUST KIND OF GOING TO GIVE YOU AN OVERVIEW OF WHAT THAT MEANS.
WHO ARE SOME CANDIDATES -- OOPS WOW.
I'M GETTING YOU THROUGH A WHOLE LOT OF THOSE.
I DON'T' WHAT'S DOING THIS, BUT IT'S SKIPPING LIKE A GILLION.
BUT IT'S SKIPPED A WHOLE LOT OF MY THINGS AND MY PICTURES.
LET'S SEE WHAT'S HAPPENED HERE.
WELL, THAT'S SAD. I COPIED THIS LAST NIGHT FORM MY OTHER FILES.
SO YOU KNOW WHAT, I'M GOING INTO MY OTHER FILES.
TRYING TO KEEP IT SIMPLE FOR MYSELF.
IT'S TOO BAD. I DIDN'T COPY IT. SO WE'RE OUT OF LUCK.
SORRY THERE IS ONLY LIKE 3 SLIDES LEFT AND IT SKIPPED ALL MY PRETTY PICTURES.
SO WE'LL JUST HAVE TO DO IT WITH OUR MINDS.
ALRIGHT, ENTERAL FEEDING. CANDIDATES FOR THAT ARE PEOPLE WITH CANCER.
LIKE IF THEY HAVE HEAD OR NECK CANCER, MOUTH CANCER THEY CAN'T CHEW OR GET THEIR FOOD DOWN,
WE MIGHT PUT A TUBE DOWN THEIR THROAT OR INTO THEIR STOMACH.
SOMEONE HAS NEUROLOGICAL OR MUSCULAR DISORDER LIKE A STROKE, DEMENTIA,
MYOPATHY, PARKINSON'S DISEASE.
REMEMBER A LOT OF PATIENTS I'VE PUT DOWN HAVE JUST BEEN TOO CONFUSED TO FEED THEMSELVES.
SO WE HAD TO PUT SOME, KIND OF, TUBE IN TO GET THE NUTRIENTS IN THEM.
GASTROINTESTINAL DISORDERS LIKE FISTULA OR IRRITABLE BOWEL DISORDERS LIKE CROHN'S.
WE'LL LOOK AT SOME OF THOSE. MILD PANCREATITIS.
RESPIRATORY FAILURE WITH PROLONGED INCUBATION.
I'M LOOKING AT THAT I'M THINKING OF SOME STROKE PATIENTS,
AN ANOREXIC, DIFFICULTY CHEWING SWALLOWING, BUT ALSO BABIES WHEN THEY'RE BORN
AND THEY'RE IN RESPIRATORY DISTRESS,
THEY NEED THE NUTRIENTS, SO WE'RE PASSING TUBES.
BECAUSE EATING WAS TOO MUCH STRESS IT CAUSES THEM TO BREATHE TOO MUCH AND TOO HARD,
SO YOU DROP TUBES.
THERE ARE THREE BASIC KIND OF TUBES,
ENTERAL TUBES THAT I WANTED YOU TO BE AWARE OF.
THE NASOGASTRIC TUBE. IT'S CALLED THE NET.
NASOENTERIC TUBE.
AND THAT'S THE TUBE THAT GOES IN FROM THE NOSE DOWN THROUGH THE ESOPHAGUS INTO THE STOMACH.
THERE IS THE JEJUNAL. AND THAT CAN BE ONE OF TWO WAYS.
IT CAN GO IN FROM THE NOSE DOWN FROM THE ESOPHAGUS INTO THE STOMACH.
AND IT HAS A LITTLE WEIGHT ON IT.
AND THE WEIGHT PULLS IT ON DOWN INTO THE JEJUNAL, THE INTESTINE.
OR GASTRIC TUBES. AND WHEN THEY TALK ABOUT GASTRIC TUBES,
THEY'RE USUALLY TUBES THAT ARE PUT IN IN SURGERY THROUGH EDOSCOPY
OR THROUGH ANOTHER SURGICAL PROCEDURE.
AND THEY PUNCTURE INTO THE STOMACH OR INTO THE INTESTINE A HOLE
AND THEN THEY PUT THE TUBE IN THAT WAY.
THE SURGEON CAN PUT THE TUBE IN
AND THEN WE CAN TAKE AND REPLACE THE TUBE EVERY THREE MONTHS OR SIX MONTHS OR WHATEVER
BECAUSE THEY DO GET A LITTLE WORN DOWN.
SOMETIMES THEY'LL PUT A TUBE IN AND THE TUBE IS SIMILAR TO WHAT THE FOLEY CATHETER IS.
YOU KNOW HOW WE PUT A FOLEY CATHETER IN AND FILL UP A BALLOON,
SO IT DOESN'T COME OUT.
THAT'S THE SAME THING THAT THESE PEG TUBES THAT YOU'VE SEEN OR FEEDING TUBES.
THEY JUST HAVE A BALLOON THAT KEEPS THEM FROM FALLING OUT.
BUT SOMETIMES THE STOMACH -- THE ACIDS FROM THE STOMACH
THEY KIND OF EAT AWAY THE BALLOON
AND THE BALLOON WILL BREAK AFTER A FEW WEEKS OR A MONTH.
AND SO WE WILL END UP PUTTING IN ANOTHER TUBE COS THEY NEED IT FOR THEIR NUTRITION.
AND WE'LL TALK MORE ABOUT THAT. NASOGASTRIC TUBES SHOULD BE USED FOR SHORT-TERM FEEDING,
NOT FOR LONG TERM.
WHY?
RISK FOR ASPIRATION.
WE'RE PUTTING FOOD IN WE DON'T KNOW WHERE THAT TUBE IS,
OTHER THAN THE FIRST TIME WE CHECKED FOR X-RAY.
BUT THEY'RE AT HIGH RISK FOR ASPIRATION.
SO WE CONSIDER SHORT TERM BEING ABOUT FOUR WEEKS.
AND IF THEY'RE GOING TO NEED THAT TUBE FOR LONGER,
TWO MONTHS, THREE MONTHS, SIX MONTHS,
WE'RE GOING TO BE LOOKING AT --
THE DOCTORS ARE GOING TO BE LOOKING AT PUTTING IN A GASTRIC TUBE OF SOME SORT A G TUBE,
OR SOME KIND OF LOWER, JEJUNOSTOMY TUBE.
THE OTHER THING ABOUT SHORT TERM IS --
YOU'RE GOING TO SEE THESE TUBES WHEN WE GET THEM OUT IN THE SKILLS LAB
AND CAN YOU IMAGINE HOW IRRITATING IT IS TO THE NOSE
AND AREAS IN THE SKIN AND THE THROAT.
SO THEY CAN BE VERY IRRITATING AND ACTUALLY COS THE MUCOSA TO BREAK DOWN.
BECAUSE OF THE WEARING OF THE TUBE AND THAT FOREIGN BODY.
SO WE WANT TO DO SOMETHING ELSE THAT'S NOT A TRAUMATIZING.
LONG TERM IS USUALLY GREATER THAN FOUR WEEKS.
WHEN THEY MADE A G TUBE, A GASTROSTOMY TUBE,
THEY PUT THE HOLE IN AND THEY CALLED THAT LITTLE HOLE A STOMA.
AND IT USUALLY TAKES ABOUT A MONTH FOR THAT STOMA TO HEAL.
HOWEVER, THE STOMA IS VERY VASCULAR.
AND IF THE TUBE WERE TO FALL OUT AND STAY OUT FOR A FEW HOURS,
IT WILL CLOSE ITSELF OFF AND SEAL AND YOU WON'T BE ABLE TO GET THE TUBE IN.
SO IT'S REAL IMPORTANT THAT WE MAINTAIN THAT HOLE, THAT STOMA IS OPEN.
REMEMBER IN HOME CARE PEOPLE WILL CALL AND SAY, "MY G TUBE FELL OUT.
CAN SOMEONE COME, YOU KNOW, PUT IT BACK IN?" WELL, THAT'S FINE.
BUT IF THEY LIVE IN SOME CITY WAY FAR AWAY, HOW ARE YOU GOING TO GET THERE, YOU KNOW,
WITHIN THE TWO-THREE HOURS THAT YOU HAVE. SO WE WOULD TELL 'EM JUST TO RINSE OFF THE OLD TUBE,
AND TO STICK IT BACK IN TO HOLD THE HOLE OPEN.
THEREFORE, IT'S NOT A STERILE PROCEDURE.
SO THAT WE WOULD STILL HAVE THE HOLE TO SET UP WITH THE NEW PIECE OF EQUIPMENT.
SO IT'S REAL IMPORTANT THAT THESE ARE MANAGED AND SO THAT THEY DON'T CLOSE UP.
ALRIGHT. NG INSERTION.
JUST BRIEFLY. YOU CHOSE A TUBE THAT'S APPROPRIATE TO WHAT THE DOCTOR HAS ORDERED,
AND THE TUBES THAT WE PUT INTO PATIENTS, LET'S JUST TALK NASOGASTRIC TUBES,
ARE MEASURED BY FRENCH, WHEREAS WITH OUR SYRINGES THE WITH OF THE SYRINGE IS GAUGE.
THE HIGHER THE GAUGE WHAT?
THE SMALLER THE WIDTH.
ON FRENCH MEASUREMENTS, WHICH ARE WHAT ARE NG TUBES ARE AND ARE FOLEY CATHETER TUBES,
THE HIGHER THE NUMBER THE BIGGER THE DIAMETER, THE BIGGER THE TUBE.
ON AN AVERAGE ADULT, WHEN WE'RE DROPPING A TUBE,
WE WOULD PUT ANYTHING IN FROM 12 TO 16 FRENCH.
THAT'S AVERAGE. BUT ON A CHILD WE'RE GOING TO HAVE SOMETHING PRETTY SMALL.
WE'LL TALK MORE ABOUT HOW YOU DETERMINE WHAT SIZE YOU'RE GOING TO PICK,
IT'S GOING TO BE BASED ON PATENCY OF NOSE,
BUT IT'S ALSO GOING TO BE BASED ON WHAT ARE YOU DOING WITH THEM.
IF YOU'RE DROPPING A TUBE BECAUSE YOU HAVE ASPIRATE STOMACH CONTENTS OUT,
YOU NEED A WIDER TUBE SO YOU CAN GET STUFF OUT.
IF YOU'RE JUST PUTTING THIN FLUIDS IN LIKE FEEDING TUBES,
WE MIGHT HAVE A TUBE AS SMALL AS 8 FRENCH JUST TO PUT IN LIQUIDS.
SO YOU REALLY HAVE A FAIRLY WIDE RANGE OF DIAMETER.
YOU CAN IMAGINE THAT A 16 FRENCH TUBE DOWN SOMEONE'S NOSE
IS A LOT MORE IRRITATING THAN AN 8 FRENCH.
AND THE EIGHT FRENCH ARE MADE OUT OF SOFT PLASTIC.
SO JUST KNOWING WHAT THEY NEED IT FOR AND HOW LONG IT WILL BE THERE.
WE MEASURE THE TUBE BY MEASURING FROM THE NOSE, TIP OF THE TUBE,
THE NOSE TO THE EAR LOBE TO THE XIPHOID PROCESS AND WE MARK IT THERE.
SO THE TIP OF THE TUBE, I MEAN THE END, THE DISTAL END THAT GOES IN THE STOMACH END.
THE PROXIMAL END IS THE END THAT'S COMING OUT OF THAT.
ALRIGHT?
SO THAT MAKES SURE THAT THE --
THAT BY THE TIME IT PASSES FROM NOSE, ESOPHAGUS, THAT IT'S INTO STOMACH.
WE LUBRICATE IT, PUT IT IN TILL ABOUT THEIR GAG REFLEX
BY PRESSING DOWN AND TOWARDS THEIR EAR. YOU DON'T PRESS UP.
WE HAVE THE VISUAL ILLUSION THAT THE NOSE GOES UP BECAUSE WE HAVE THIS BRIDGE OF NOSE,
BUT REALLY THE TURBINATE GOES DOWN.
SO YOU PUT PRESSURE DOWN AND TOWARDS THE EAR.
AND IT GETS TO THE BACK OF THEIR THROAT AND THEY GO...
AND YOU KNOW THAT YOU'RE AT THE GAG REFLEX, SO YOU PULL BACK,
LET 'EM GET COMPOSED.
THEN IF THEY'RE ABLE AND THEY CAN DRINK FROM A STRAW,
YOU HAVE 'EM DRINK FROM A STRAW, PULL THEIR HEAD, CHIN DOWN.
YOU HAVE TO HAVE A STRAW IN THIS ONE BECAUSE HOW CAN YOU DRINK IF YOUR CHIN IS DOWN?
WHY WOULD YOU WANT CHIN DOWN?
CLOSES OFF THE AIRWAY.
BECAUSE WE DON'T KNOW. THIS IS A BLIND TREATMENT.
IT CAN EITHER GO DOWN THE TRACHEA
OR IT CAN GO DOWN THE ESOPHAGUS TO THE STOMACH.
AND WE DON'T WANT IN THE TRACHEA BECAUSE THEN THEY CAN'T BREATHE AND THAT'S A PROBLEM.
SO WE HAVE 'EM PUT THEIR HEAD DOWN AND DRINK.
THE OTHER THING THAT HAPPENS WHEN YOU DRINK IS IT CLOSES OFF THAT TRACHEA.
SO AS THEY DRINK...
PUT THE REST IN TILL IT MEETS THAT LINE AND THEN YOU STOP. A LITTLE UNCOMFORTABLE.
WHEN WAS THE LAST TIME YOU KIND OF GOT SOCKED IN THE NOSE OR SOMETHING IN THE NOSE?
VERY UNCOMFORTABLE.
SO THEY GET THEIR COMPOSURE AND THEIR BEARINGS.
WE'RE GOING TO JUST TAPE IT HERE FOR A MOMENT AND THEN WE'RE GOING TO CHECK FOR PLACEMENT.
THIS IS IMPORTANT FOR YOU TO KNOW.
WE'RE GOING TO CHECK PLACEMENT BY CHECKING PH.
IT'S THE MOST ACCURATE MEASURE OF PLACEMENT.
PH FOR THE STOMACH, WE ALREADY KNOW IS FOUR OR BELOW.
IF WE GET A PH OF SIX TO EIGHT, IT'S PROBABLY IN THE LUNGS.
AND IF IT'S ABOVE THAT, LIKE AROUND SEVEN OR EIGHT,
IT'S PROBABLY IN THE INTESTINE.
SO WE'RE GOING TO CHECK PH.
WE'RE GOING TO ASPIRATE AS WELL TO SEE IF WE GET STOMACH CONTENTS.
PRETTY GOOD SIGN IF YOU GET SOME BILE.
YOU KNOW, OR THEY JUST HAD SOMETHING AND YOU'RE GETTING...
I DON'T KNOW. BLOODY, COFFEE GROUND LIKE STUFF
BECAUSE THEY'RE THERE WITH AN ULCER, BUT YOU GET STOMACH CONTENTS.
NOW WE AT LEAST HAVE AN IDEA THAT WE THINK WE'RE IN THE STOMACH.
WHAT IF I DIDN'T GET ANYTHING BACK AND THEY'RE KIND OF TURNING A LITTLE BLUE.
WE CALL IT CIRCUMORAL CYANOSIS AROUND HERE.
WHERE DO YOU SUPPOSE IT LANDED?
PROBABLY IN THEIR TRACHEA. BEST BE GETTING THAT THING OUT OF THERE.
WE DON'T WANT TO GIVE A FEEDING WITH THAT IN THE LUNGS.
OKAY? IT CAN KILL SOMEBODY.
ONCE WE'VE DETERMINED THAT WE'RE PRETTY CONFIDENT IT'S IN THE STOMACH,
THEN WE GET AN X-RAY.
NOW I JUST WANT TO SHARE TWO THINGS CLINICALLY ABOUT GETTING AN X-RAY FOR YOUR NG TUBE.
IT'S THE MOST ACCURATE DETERMINATION OF WHERE THE TUBE IS.
HOW ELSE DO WE REALLY, REALLY KNOW WITHOUT X-RAY?
ANYTIME YOU'RE GOING TO BE PUTTING SOMETHING IN SOMEONE,
YOU HAVE GOT TO GET AN X-RAY, IT IS HOSPITAL POLICY.
I WOULD NEVER TUBE ANYONE WITHOUT VERIFICATION OF THAT TUBE AND YOU WON'T EITHER.
BUT IN SOME OF THE HOSPITALS, IF THEY'RE PUTTING A TUBE DOWN
BECAUSE THEY'RE A GI BLEED OR THEY'RE HAVING --
THEY HAVE AN ILIOUS, THE BOWEL'S NOT WORKING ANYMORE
AND THEY'RE NEEDING TO JUST GIVE THE STOMACH A REST
AND WE'RE NOT PUTTING ANYTHING IN,
THEY SOMETIMES DON'T GET AN X-RAY BECAUSE WE'RE GETTING CONTENTS FROM THE STOMACH.
SO WHEN YOU'RE READ IN YOUR BOOKS THAT IT SAYS,
YOU MUST, MUST, MUST GET AN X-RAY FOR PLACEMENT,
THEN YOU MUST, MUST, MUST WHEN YOU'RE FEEDING THEM.
IT'S A DIFFERENT SCENARIO. SO MAKE SURE YOU CHECK YOUR HOSPITAL POLICY.
I'VE WORKED IN HOSPITALS WHERE THEY WANT YOU TO GET AN X-RAY, PERIOD.
AND I'VE WORKED AT HOSPITALS WHERE THEY DON'T,
WHERE YOU DON'T HAVE TO FOR TAKING FLUIDS OUT.
ALRIGHT?
ONCE YOU'VE VERIFIED PLACEMENT, THEN WE SECURE IT.
AND THEN WE CHECK THE PLACEMENT ALWAYS BEFORE ANY FEEDING,
ANY MEDICATION OR ANYTHING WE'RE PUTTING IN.
ALWAYS CHECK FOR PLACEMENT.
NOW IN THE HOSPITALS HERE IN THE CENTRAL VALLEY NOBODY CHECKS PH.
I FIND THAT VERY FASCINATING BECAUSE ALL OF THE LITERATURE STILL CONCURS
AND IT HAS FOR YEARS THAT THE BEST METHOD FOR CHECKING PLACEMENT IS PH.
WELL, ONE OF THE PROBLEMS IS IS WE'RE GOING TO TALK ABOUT
WHEN WE GET TO OUT TUBE FEEDINGS HERE IN A FEW MINUTES,
IS THAT THE TUBE -- THE FEEDING ITSELF CAN RAISE THE PH.
SO IF YOU'RE ASPIRATING FEEDING,
THEN YOU ACTUALLY HAVE A HIGHER PH THAN YOU DO ON THE EMPTY STOMACH.
SO THE PH INDICATOR IS FOR AN EMPTY STOMACH.
SO THEY HAVE TO HAVE BEEN WITHOUT FOOD FOR TWO TO FOUR HOURS.
AND THEY ACTUALLY SAY IN THE LITERATURE,
"THEY'RE BEST TO HAVE BEEN WITHOUT FOOD FOR FOUR HOURS."
CHECK PH. THEN YOU KNOW.
OKAY. SO THAT'S PROBABLY WHY WE DON'T USE SO MUCH PH.
I HAD A HOSPITAL TELL ME COS I'VE BEEN ON THE BAD MIC ABOUT THIS FOR YEARS,
"WELL, WE DON'T LET NURSES CHECK PH BECAUSE THEN WE --
IT'S A LAB TEST AND WE'D HAVE TO VERIFY THAT EVERYONE WASN'T COLOR BLIND.
CAN YOU IMAGINE SUCH A THING?
SO I THOUGHT THAT WAS FAIRLY LAME, BUT WHATEVER,
THE CASE IS YOU HAVE TO VERIFY PLACEMENT.
SO ONE OF THE WAYS THAT PLACEMENT IS VERIFIED
IS BY ONCE YOU KNOW AND YOU BELIEVE IT TO BE IN THE RIGHT PLACE,
YOU TAKE 30 MILLILITERS OF AIR, CONNECT TO SYRINGE WITH AIR TO THE DISTAL PROXIMAL END THERE.
AND YOU PUT YOUR STETHOSCOPE TO THE STOMACH RIGHT BELOW THE XIPHOID PROCESS.
AND INSERT 30 MILLILITERS OF AIR.
AND YOU SHOULD BE ABLE TO HEAR THE WHOOSH OF THE AIR.
AND THAT IS...
MOSTLY TRUE IF IT'S IN THE RIGHT PLACE.
THE PROBLEM IS IF THE TUBE WERE RIGHT HERE,
YOU WOULD STILL HEAR THE WHOOSH RIGHT HERE
BECAUSE OF REFERRED SOUND.
SO RESEARCHERS FOUND THAT THIS IS REALLY AN INACCURATE METHODOLOGY
OF CHECKING PLACEMENT.
SO WHY DO WE KEEP DOING IT?
THEY DID A SURVEY. AND INTERESTINGLY IN THIS SURVEY, NURSING 2006,
65% OF NURSES STILL CHECK BY AIR.
THAT IS A LOT WHEN THE LITERATURE HAS SAID FOR OVER 12 YEARS NOT TO.
18% PH.
WE'VE GOT TO BE CHECKING CERTAINLY WITH X-RAY,
BUT ANOTHER MEASURE HAS BEEN HELPFUL TO US.
AND THAT IS YOU NEED TO LOOK AT THE BACK OF THE THROAT AND SEE THAT YOU SEE THE TUBE.
AND AFTER VERIFICATION BY X-RAY, MEASURE THE LENGTH OF THE TUBE
FROM THE TIP OF THE NOSE TO THE END OF THAT PROXIMAL END.
BECAUSE IF THAT MIGRATES OR MOVES IT ALL,
THAT MEASUREMENT WILL CHANGE.
THERE ARE TIMES WHEN THE STOMACH IS EMPTY AND YOU GET NOTHING.
HOW CAN YOU CHECK PH ON NOTHING IN THE STOMACH?
WHAT ARE YOU GOING TO DO? WITHHOLD THE FEEDING?
NO. IF THE TUBE IS STILL GOING DOWN AND YOU CAN SEE IT IN THE BACK OF THE THROAT
AND IF YOUR MEASUREMENT IS STILL THE SAME
AND THAT WAS THE SAME MEASUREMENT AS CONFIRMED BY X-RAY,
THEN YOU'RE GOOD TO GO. GIVE THE FEEDING.
AND YOU CAN FEEL COMFORTABLE IN THAT.
AND THAT'S WHAT THE LITERATURE AND I'LL QUOTE YOU METHENY FOR 2006.
SHE IS THE GURU OF NG TUBES. I READ HER ALL THE TIME.
SO WE HAVE TO HAVE A BACKUP PLAN WHEN THEY'RE,
"BUT, MY INSTRUCTOR SAID..." AND WE GET ALL FREAKED OUT ABOUT IT.
I NEED TO GIVE YOU THE REALITY OF THE WORLD IN WHICH WE LIVE.
SOMETIMES YOU DON'T GET ASPIRATE TO CHECK PH.
OKAY.
ONE OF THINGS ABOUT CHECKING OUR PH,
OR PUTTING OUR FOOD IN IS WE NEED TO GIVE FOOD TO PEOPLE.
BUT SOMETIMES PEOPLE DON'T DIGEST THIS FOOD VERY WELL.
SO AFTER WE'VE CHECKED FOR PLACEMENT,
AND WE'VE CHECKED PH AND WE'VE LOOKED AT ALL OF OUR STUFF,
WE DO ONE OTHER MEASURE BEFORE FEEDING
AND THAT IS WE CHECK RESIDUAL.
SO WE PULL UP WITH THESE BIG, 60-MILLILITER SYRINGE ALL OF THE FOOD,
THE FLUID AND LIQUID THAT'S IN THE STOMACH
TO SEE HOW MUCH IS LEFT IN THERE.
LET'S SAY THE DOCTOR SAID THAT I WAS SUPPOSED TO FEED MY CLIENT AT...
120 MILLILITERS OF FLUID PER HOUR.
WELL, LET'S SAY 100, THAT'LL BE 2,400 ML IN A DAY AND THAT WOULD BE ABOUT RIGHT.
LET'S SAY ABOUT 100 ML EVERY HOUR.
AND I GO TO GIVE A MEDICATION OR SOMETHING,
AND I ASPIRATE TO SEE HOW MUCH RESIDUAL IS IN
AND THERE'S STILL 80 ML OF FLUID IN THAT PERSON'S STOMACH.
ARE THEY DIGESTING THEIR FOOD? IS IT MOVING?
NO. THEY USUALLY LIKE THERE TO BE LESS THAN HALF OF THE HOURLY VOLUME AS A RESIDUAL.
SO WE WOULD WITHHOLD THE FEEDING --