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.

- 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 --