Feeding, fluids and elimination

Enteral feeding

1. Confirm tube placement before anything goes down it, and check the external marking each time.
2. Head of the bed at 30 to 45 degrees during the feeding and afterwards.
3. Check the gastric residual per policy; a large residual means the stomach has not emptied, so the feeding is held and reported rather than added to.
4. Flush before and after the feeding and between medications, and give medications separately rather than mixed into the feed.

Too little fluid, and too much

• Dehydration: thirst, dry mucous membranes, concentrated urine with a high specific gravity, tachycardia, postural drop, weight down. In an older adult, confusion is often the first thing anyone notices.
• Overload: weight up, crackles at the lung bases, distended neck veins, peripheral edema, breathlessness lying flat.

Weight is the most sensitive measure of both, and a rapid change is fluid rather than tissue — roughly one kilogram to a liter. It is taken at the same time each day, on the same scale, in similar clothing, which is what makes yesterday's figure comparable.

Stomas and catheters

• A healthy stoma is pink to red and moist. Pale, dusky or black is reported at once — the blood supply is failing.
• An ileostomy drains loose and near-continuously and dehydrates a client quickly; a colostomy further along the bowel produces more formed output.
• The appliance opening is cut to the stoma, close but not touching, so that skin is not left exposed to output.
• A catheter bag stays below bladder level and off the floor, the tubing is kept free of kinks and dependent loops, and the system is not broken to obtain a specimen — a sample is taken from the port.

The single most effective thing that reduces catheter-associated infection is not the technique of insertion. It is asking every day whether the catheter is still needed.