Nursing Process

Assessment

• Assess the tape around the nasogastric tube

• Assess sign and symptoms of intolerance to feedings

• Intake and output

• Baseline laboratory values

Nursing Diagnoses

• Risk for fluid volume deficit

• Risk for diarrhea related to tube feedings

• Potential for loss of skin integrity related to diarrhea

• Risk for aspiration

Planning

• Patient will receive adequate nutritional support

• Side effects will be managed

• No skin breakdown will occur

• Patient will not aspirate

Interventions

• Check tube placement

• Check for gastric residual before intermittent or bolus feedings

• Check continues feedings for residual every 2 to 4 hours

• Feeding should be at room temperature

• Flush feeding tube based on method of delivery

• Monitor side effects such as diarrhea

• Dilute drug solutions appropriately

• Monitor vital signs

• Monitor hydration

• Weigh patient daily

• Change feeding bag daily

Education

• Patient should report diarrhea, sore throat, and abdominal cramping Evaluation

• Patient will not lose weight

• Patient will not have skin break down

• Patient will not experience diarrhea, abdominal cramping or distention

• Patient will remain in a positive nitrogen balance

• Patient will not become dehydrated

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