Alternate Nutrition and Hydration (ANH)

Question 1

1. ANH (2)

2. Decision based on:

Answer 1

1. Considered when the patient has a functional gastrointestinal tract but is unable to meet nutritional needs by mouth for a variety of reasons.
2. Also used when the patient does not have a functional GI tract.

— We rec. alternate nutrition and hydration

2. Decision based on:
   a. clinical and instrumental examinations of swallowing;
   b. medical status;
   c. nutritional status; (may need tube and oral feeding)
   d. behavioral/cognitive status.

Question 2

Non-oral Feeding

Answer 2

Nutrition not taken by mouth can be divided into two main groups:

1. Parenteral- given through a vein (pic line)
2. enteral (tube)

Question 3

Parenteral nutrition

Answer 3

1. Given intravenously into either a peripheral vein, or a large central vein
   a. such as the jugular or subclavian.
2. A central vein allows hypertonic (more concentrated) solutions to be infused.
3. It bypasses the gastrointestinal system.

Question 4

Parenteral nutrition (Indications for use)

Answer 4

1. Supplemental hydration (IV)
2. Restoration of fluid and electrolyte balance (Central line)
3. TPN- get calories from this (but still doesn’t go through the GI tract)

Question 5

Possible complications of parenteral complications

1. Simple IV (4)

Answer 5

1. Infection
2. Edema
3. Bleeding
4. Weakened & collapsed veins

Question 6

Possible complications of parenteral complications

1. Central Line- Subclavian Vein (7)

Answer 6

1. Air embolism
2. Pneumothorax
3. Myocardial perforation
4. Phlebitis
5. Blood clot
6. Infection
7. Sepsis

Question 7

Non-oral alternatives (Enteral options) (4)

Answer 7

1. NG/NJ tube NG- nasogastric, Nasojejunum- to small intestine
2. DHT- very small and very flexible
3. PEG- percutaneous (through the skin) endoscopic gastrostomy
4. PEJ- percutaneous endoscopic jejunostomy
   - NG tube is as wide as pinky and not flexible, not comfortable
   - DHT and NG/NJ are short term
   - PEG or PEJ – long term

Question 8

Enteral nutrition

Answer 8

1. refers to nutrition given directly into the gastrointestinal system
2. allows more natural absorption of nutrients to occur.
3. It can be given through
   a. nasogastric (NG/DHT) tubes manually placed
   b. PEG or PEJ tubes placed endoscopically and percutaneously with radiologic guidance.
   c. gastrostomy or jejunostomy tubes placed surgically (may need to be done if pt. has too much scar tissue or other complications)
4. Nasogastric tubes are commonly used in hospitals.
5. The standard polyvinyl tube is uncomfortable and can be irritating to the nasal, esophageal and gastric tissue. (width of pencil, irritating)
6. Smaller, more flexible tubes made of silicon and polyurethane are more comfortable and thought to be less irritating to the
   a. Oropharynx
   b. Esophagus
   c. Esophageal sphincter.

Question 9

Indications for use for NG/NJ and DHT

Answer 9

1. Short-term alternative (~ 2 weeks)
2. Transnasal insertion
3. Easily removed

*** Can be 6-8 weeks, but the less time the better

Question 10

Possible Complications of enteral nutrition (6)

NG/JG or DHT

Answer 10

1. Misplacement into the airway
2. Irritation to nasal, pharyngeal, esophageal mucosa
3. Discomfort
4. Negative cosmesis
5. May contribute to reflux & aspiration (goes through UES and LES, so causes leakage)
6. May impact swallow function

*** placed at bedside so complications are common

*** pt. may try to tear them out

Question 11

Gastrostomy or jejunostomy tubes

Answer 11

1. Gastrostomy or jejunostomy tubes are preferred for long-term enteral nutrition.
2. With their use, patients no longer have to deal with the nasopharygeal irritation associated with NG tubes.

– They can still eat, there are no cosmetic issues, under clothes

3. Does not necessarily preclude oral intake

Question 12

Possible Complications (PEG) (8)

Answer 12

1. Nausea
2. Vomiting
3. Diarrhea (#2)
4. Constipation
5. Reflux
6. Clogged tube (small tube, pills can get stuck)
7. Skin irritation (#1)
8. Aspiration

Question 13

Indications for Use (PEJ)

Answer 13

1. Does not require stomach in digestion
2. Enteral nutrition earlier after stress or trauma
3. Less risk of reflux and aspiration (deeper in the system)
   - Bypasses the stomach, right into the intestines

Question 14

Possible Complications (PEJ) (4)

Answer 14

1. Loss of controlled emptying of the stomach
2. Misplacement
3. Diarrhea
4. Dehydration- less time for the liquid to be absorbed

Question 15

Non-oral feeding with intermittent bolus feeding

Answer 15

1. clothing can cover the tube when the patient is not receiving feedings
2. allows fuller freedom to participate in activities without being obvious to others that there is a tube present.

Question 16

Hypodermal Clysis

Answer 16

• Subcutaneous placement used as a hydration supplement for mild-moderate dehydration
• Mild subcutaneous edema – possible complication

Question 17

Issues in decision making- non-oral feeding

Answer 17

1. When a feeding tube is being considered
   a. share all available information with the patient and his or her family.
2. Questions must be answered by the care team and family members to help arrive at the best decision regarding tube placement.
   a. Know the underlying condition that resulted in feeding tube placement.
   b. Document the contents of any conversation you have with the patient and family regarding this issue.
   c. Know the prognosis based on the illness
   d. Is tube placement only for short-term, like getting over pneumonia or do they have a progressive terminal illness.
   - Swallowing in first time strokes usually resolves
   - If it is a degenerative disorder, it won’t get better

Question 18

Common misconceptions for ANH (5)

Answer 18

1. aspiration pneumonia
2. malnutrition
3. dehydration
4. provide comfort
5. prolong life
   - It can do all of these things, but there are times when it does none of these.

Question 19

Our responsibility re: recommending ANH (4)

Answer 19

1. Consider current condition
2. Consider prognosis
3. Completely discuss treatment options (pros, cons, benefits and risks) with family
4. Consider patient/family values, beliefs and wishes
   - (more on these concepts in another lecture)