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MNT II > Ch 5 - EN and PN > Flashcards

Ch 5 - EN and PN Flashcards

1
Q

EN

A

Feeding provided through the GI tract via a tube, catheter or stoma that delivers nutrients distal to the oral cavity

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2
Q

PN

A

intravenous administration of nutrients

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3
Q

EN Advantages

A

o Intake easily/accurately monitored
o Increased compliance with intake
o Provides nutrition when oral is not possible or accurate
o Costs less than parenteral nutrition
o Supplies readily available
o Preserves gut integrity – better GI barrier function
o ↓ likelihood of bacterial translocation
o Preserves immunologic function of gut → preserves gut-associated lymphoid tissue (GALT) activity
o ↓ rates of infection unrelated to GI tract

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4
Q

EN Disadvantages

A 
o	Potential Complications
•	Tube displacement, obstruction or clog
•	Contamination of formula
•	GI complications
o	Costs more than oral diets
o	Less “palatable / normal”
o	More labor intensive
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5
Q

Which Patients Need EN?

A
  • Impaired ingestion
  • inability to consume adequate oral nutrition
  • impaired digestion, absorption, metabolism
  • severe wasting or depressed growth
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6
Q

Impaired ingestion (EN)

A
  • Neurologic disorders/comatose state
  • Traumatic brain injury
  • HIV/AIDS
  • Facial trauma
  • Oral or esophageal trauma or cancer
  • Congenital anomalies
  • Respiratory failure
  • Cystic fibrosis
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7
Q

Inability to consume enough oral nutrition (EN)

A
  • Hyperemesis of pregnancy
  • Hyermetabolic states such as burns
  • Anorexia in congestive heart failure, cancer, COPD
  • Congenital heart disease
  • After orofacial surgery or injury
  • Spinal cord injury
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8
Q

Impaired digestion, absorption, metabolism (EN)

A
  • Severe gastroparesis
  • Crohn’s Disease
  • Short bowel syndrome
  • Pancreatitis
  • Inborn errors of metabolism
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9
Q

Severe wasting or depressed growth

A
  • Cystic fibrosis
  • Failure to thrive
  • Cancer
  • Critical illness, trauma, burn
  • Cerebral palsy
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10
Q

Nasogastric EN

A

3-4 weeks
Normal GI
Bolus, intermittent or cont.

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11
Q

Nasoduodenal or Nasojejunal EN

A

3-4 weeks

gastric motility disorders, esophageal reflux or persistent nausea and vomiting

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12
Q

Percutaneous Endoscopic Gastrostomy (PEG) or jejunostomy (PEJ)

A

nonsurgical

>3-4 weeks

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13
Q

1F (French unit)

A

1F = 33mm diameter

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14
Q

Standard Formulas (EN)

A

• Lactose-free, 1kcal/mL
- Over-the-counter supplements
- Formulas designed specifically for tube feeding
• Some have fiber, some don’t
• Concentrated standard formulas: 1.5 – 2 kcal/mL for fluid restriction

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15
Q

High-Nitrogen EN Formulas

A

burns, fistulas, sepsis, trauma

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16
Q

Chemically-defined EN Formulas

A

• Some called “elemental”
• Low in fat, supplemented with MCT
- Long term use → EFA deficiency – need to monitor
• Protein fragments: dipeptides, tripeptides or oligopeptides

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17
Q

Disease Specific EN Formulas

A
  • Kidney disease
  • Liver disease
  • Glucose intolerance/diabetes
  • Pulmonary failure
  • Immunosuppression
  • Wound healing
  • Expensive and controversial efficacy
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18
Q

Modular Formulas

A
  • Individual macronutrients
  • Protein
  • Carbohydrate
  • Fat
  • Occasionally combination products used
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19
Q

Protein EN

A
  • 10-37% of kcals
  • intact versus hydrolyzed affect osmolality
  • High-protein
  • Glutamine and arginine
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20
Q

Carbohydrates EN

A
  • 30-90% of kcals
  • Source and degree of hydrolysis affect osmolality
  • Lactose is not used
  • Addition of fiber
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21
Q

Fat EN

A
  • 1.5% - 55% of kcals
  • 2% – 4% as linoleic acid
  • Corn oil, soybean oil, MCT oil, Fish oil
22
Q

Water EN

A

70-85%

23
Q

Adult Water Requirements

A

1 mL/kcal or 35 mL/kg

24
Q

Infant Water Requirements

A

1.5 mL/kcal or 150 mL/kg

25
Q

Elderly Water Requirements

A

25 mL/kg for renal, liver or cardiac failure

35 mL/kg for hx of dehydration

26
Q

Vit/Min Supplement EN

A

If not meeting 100% of RDI’s → 15 mL/day multivit/mineral elixer via feeding tube

If pt should not get minerals → 5 mL multivitamin elixer

27
Q

Residue

A

Fat, fiber, lactose

28
Q

Osmolality EN

A

Concentration of particles in a solution (mOsm/kg of water)
EN
Blood = 285 - 290 mOsm/kg

29
Q

Lower Osmolality EN

A

Large (intact) proteins - soy isolates, sodium or calcium casein, lactalbumin
Large starch molecules
Better tolerated

30
Q

Higher Osmolality EN

A

Hydrolyzed proteins or amino acids
Disaccharides
May cause diarrhea if infused too quickly

31
Q

Osmolarity (PN)

A

unit of measure is mOsm/L of entire solution

Includes liquids and solids

32
Q

Bolus EN

A

Normal method
Best for ambulatory pts

4-6 “meals”/day, 250-500 mL rapid infusion (<10 mins)
Order by # cans/day

Syringe or gravity drip
Start with .25 - .5 goal then work up to goal
Only stomach because reservoir capacity
Check nausea, vomit or excessive bloating

33
Q

Intermittent EN

A

Everything is the same as bolus except 250-500 mL formula over 20-40 mins via gravity drip bag only

34
Q

Continuous EN

A

24 hour pump
Gastric or SI
30-50 mL/hour start → increase by 20 mL/hour every 4-8 hours as tolerated until goal rate is reached
Most common hospital feeding

35
Q

Cyclic EN

A 
Pump over night 
150 mL/hour max
Compress over a few days 
 - Day 1: 20 hours
 - Day 2: 16 hours
 - Day 3: 12 hours 
Always for jejunum 
Controls overflow
36
Q

GI Tolerance Symptoms

A 
Nausea vomiting diarrhea
constipation, cramps
abdominal distention
esophageal reflux
high gastric residual volumes - stomach is not emptying properly
37
Q

Pulmonary complications

A

Respiratory distress - reflux of GI residue - decrease vol

aspiration

38
Q

Hydration status

A

monitor urine output, weight change and output vs. input daily

39
Q

Lab Symptoms

A

Dehydration = High Na, High BUN:creatinine ratio
Hyper/hypoglycemic before
Electrolyte imbalances - monitor K, Mg and P daily
Nutritional Parameters

40
Q

Access Complications

A

Tube Displacement
breakage/malfunciton
leakage
obstruction

41
Q

Tube obstruction

A

Meds not crushed
inadequate flushing
viscous formula used in small tube

42
Q

GI Complications

A 
Nausea/vomiting
delayed gastric emptying with sedatives or pain meds
high gastric residuals
malabsorption
diarrhea
constipation
43
Q

Diarrhea

A

Number one complication with EN

  1. Is stool output quantified?
  2. What meds? Mg can cause diarrhea
  3. Is the patient receiving antibiotics?
  4. C. difficile?
  5. More or less fiber?
  6. Need isotonic formula? Hyperosmolar formula used with severe heart failure for fluid restricted diet causes diarrhea
  7. Need antidiarrheals?
  8. Need probiotics?
  9. Need pancreatic enzymes or an elemental formula?
44
Q

Constipation

A

Monitor meds, EN formulation (concentration, fiber), adequate water

Consider “bowel regimen” - stool softeners/laxatives

45
Q

Microbial contamination

A

Max 8 hour hang time

change En feed bags/tubing every 24 hours

46
Q

Aspiration

A

Reflux of EN - inhales formula into lungs - pneumonia - death

High risk patients: poor gag reflex, depressed mental status, esophageal reflux disease

47
Q

Reducing Aspiration Risk

A

Check gastric residual volume if receiving gastric feedings - hold feed if >250-500 mL - may need prokinetic to stimulate GI motility

Head >30 degrees while feeding

Postpyloric feeding

48
Q

Gastric Residual Volume

A

60 mL syringe used to feed and withdraw contents - attach syringe to withdraw and then refeed into stomach to preserve acid

49
Q

Hyperglycemia Risk

A

Diabetes, obese, metabolic stress, steroid rx
every 6 hours with finger stick
establish monitoring plan before patient goes home

50
Q

Refeeding Syndrome

A

Hypokalemia - Heart won’t work
Hypophosphatemia - muscle/respiratory failure
Hypomagnesemia - cardiopulmonary failure

Complications from fluid overload
Carb intake should be conservative

If any levels drop, replete IV if possible

Limit to 1000 kcals/day until electrolytes are stable

51
Q

Nutritional Parameters

A

Weight - 3x/wk
S/S of edema and dehydration - daily
Fluid intake/output - daily
Adequacy of EN intake - 2x/wk
Nitrogen balance, 24 hour urine urea nitrogen - weekly
Gastric residuals - every 4 hours
Serum electrolytes, BUN, creatinine - 2-3x/wk
Serum glucose, Ca, Mg, P - weekly or as ordered
Stool output and consistency - daily

MNT II (1 decks)

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