Chapter 10: Overview of EN

Question 1

Name 6 benefits in EN feeding.

Answer 1

Nutrients provided via the enteral route undergo first-pass metabolism, 1. promoting efficient nutrient utilization. The presence of nutrients in the SI maintains normal gallbladder function by stimulating the release of cholecystokinin, 2. reducing the risk of cholecystitis that may occur if patients are kept NPO.

3. Luminal nutrients provide GI structural support and
4. help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
   ((this is via: IgA, which is secreted within the GI tract when there are nutrients, can prevent bacterial adherence and translocation))
5. EN reduces infectious complications
6. less expensive than PN

Question 2

Name 8 contraindications for EN.

Answer 2

1. Severe Short Bowel Syndrome (<100-150 cm remaining small bowel in the absence of the colon, OR 50-70 cm remaining small bowel in the presence of the colon).
2. Other severe malabsorptive conditions
3. Severe GI bleed
4. Distal high-output GI fistula
5. Paralytic ileus
6. Intractable vomiting and/or diarrhea that does not improve with medical mgmt
7. Inoperative mechanical obstruction
8. When the GI tract cannot be accessed – ie: when upper GI obstruction prevent feeding tube placement

Question 3

Placement of long-term feeding tubes is indicated if EN is expected to last longer than..?

Answer 3

4-6 weeks

Question 4

Define standard EN formulas

Answer 4

meet normal requirements for most patients; energy density of 1-2 kcal/ML; may or may not contain fiber

Question 5

Define disease-specific EN formulas

Answer 5

Designed for patients with renal/hepatic disease, diabetes, pulmonary (COPD, ARDS) disease, and immunocompromised patients; elemental and semi-elemental options available

Question 6

Define modular components.

Answer 6

Can be co-administered via feeding tube to provide additional:

1. Energy (maltodextrin, hydrolyzed corn starch)
2. Fat (fish oils, MCTs, etc)
3. Protein (powdered calcium caseinates, whey protein concentrates)
4. Individual AA (glutamine, arginine)

Note these are not mixed directly with EN formulas because they may clog the feeding tube.

Question 7

What is the typical dose for thiamin supplementation?

Answer 7

100 mg thiamin daily for 5-7 days

Question 8

(True or False) Aspiration of gastric contents is less likely to result in bacterial colonization of the respiratory tract than oral secretions.

Answer 8

TRUE

Question 9

What type of EN route of delivery reduces risk of aspiration?

Answer 9

Post-pyloric; which reduces the volume of stomach contents; shown to have a 30% lower rate of aspiration than gastric feeding

Question 10

(True or False) Gastric feeding is considered safe for most patients.

Answer 10

TRUE

Question 11

(T/F) Gastric feeding is preferable if waiting for migration of a feeding tube tip past the pylorus will delay the early initiation of EN.

Answer 11

TRUE

Question 12

**What is the ASPEN recommendation for when EN needs to be initiated in a well-nourished patient?

Answer 12

**NPO/Inadequate oral intake x 7-14 days

Question 13

**What is the ASPEN recommendation for when EN needs to be initiated in a high-risk critically ill patient?

Answer 13

***Within 24 - 48 hours of initial insult (mechanical ventilation, surgery, neurologic injury) (“Early EN initiation”

Question 14

Pump-assisted continuous drip infusions

Answer 14

Preferred method for critically ill patients, who are vented (using oro-tracheal method), at risk for refeeding, have poor glycemic control, have jejunostomy tube, or have an intolerance to intermittent gravity or bolus feeding

Question 15

Gravity drip method

Answer 15

(Without use of a pump), may be used to provide continuous drip feedings to the non-critically ill patient living at home or outside the hospital setting

Question 16

Cyclic feedings

Answer 16

Uses pump or gravity drip, over a time period that is less than 24 hours. Minimum infusion time per day is 8 hours, depending on volume tolerance

Question 17

Intermittent feedings

Answer 17

Uses infusion pump or gravity drip; selected for patients with feeding tubes that terminate in the stomach to accommodate the larger volumes administered in a shorter time period

Volumes range from 240 - 720 mls (1 - 3 cups)
Administered time period ranges from 20 - 60 mins
Can be provided from 4 - 6 times / day, depending on volume required

Question 18

Bolus feedings

Answer 18

Provide a set volume of formula at specified time intervals over a VERY SHORT period of time, usually with a feeding syringe.

Typical feeding: 240 mL of formula over a 4 - 10 min. period, with infusions 3 - 6 times/day, with at least 3 hours between feedings

These can also be administered with the gravity drip method, which the rate of formula is regulated by adjusting a roller clamp.

Question 19

What is the recommended EN initiation for critically-ill patients?

Answer 19

Start at 10 - 40 mL/hr, increasing by 10 - 20 mL/hr Q 8 - 12 hours to goal rate.

Many critically-ill patients can tolerate rapid advancement of EN to goal rate within 24 - 48 hours, minimizing energy and protein deficits.

Question 20

Volume-Based feeding

Answer 20

prescribed in terms of the goal volume per day, rather than goal volume per hour; more recent feeding method used in the critically-ill patient population

EN formulas are typically started at goal rate, or rapidly advancing to the goal

Question 21

Define hemodynamically unstable.

Answer 21

Defined as those with a mean arterial BP of less than 150 mmHg, or those who are starting vasopressor meds, or require increasing doses to maintain BP

Ischemia bowel may occur as a result of reduced blood flow to the gut, a potential consequence of low BP

Question 22

Hypocaloric feeding

Answer 22

Defined as 65 - 70% of energy needs as estimated by IC (or calculations); provided as high-protein hypocaloric EN, designed for critically-ill obese patients to minimize the metabolic complications of feeding, preserve LBM and mobilize fat stores

Question 23

What are the energy recommendations for critically-ill patients w/ sepsis, starting EN?

Answer 23

Provide 60 - 70% of energy needs (with 100% estimated protein needs), during the first week of EN. Then advance to more than 80% of estimated energy needs after the first week.

Question 24

Define trophic feeding. When is it indicated, and for which patients?

Answer 24

10 - 20 mL/hr or up to 500 kcal/day; indicated for patients with ARDS or acute lung injury who are expected to be vented for more than 72 hours AND not high nutrition risk or malnourished.

Question 25

List factors that increase the risk for clogging of the feeding tube.

Answer 25

1. Use of fiber-containing formulas
2. Use of small-diameter tubes
3. Use of silicone, rather than polyurethane tubes
4. Checking GRVs
5. Improper medication admin via the tube

Question 26

**What is the ASPEN recommendation for flushing feeding tubes?

Answer 26

**At least 30 mL water Q 4 hours during continuous feeding

OR, before and after intermittent or bolus feedings in adult patients

AND, 30 ml of water, before and after GRV checks

Question 27

What is the #1 method for preventing contamination of open feeding systems?

Answer 27

Hand-washing

Question 28

Contamination of TF formula, can cause, what?

Answer 28

Abdominal distention, diarrhea, and bacteremia

Sepsis, PNA, infectious enterocolitis

Question 29

What is the ENfit Connector?

Answer 29

A newly designed EN connector, made to help prevent enteral tubing misconnections

Question 30

**What is ASPEN/SCCM recommendations for checking GRVs in critically-ill patients?

Answer 30

• **It is not recommended, because a number of factors can compromise the accuracy of GRV checks:
  
  • feeding tube type, diameter and position
  • viscosity of GRVs
  • technique, including size of syringe and time and effot spent
  • position of the patient

*GRVs have not been found to correlate with incidence of PNA or aspiration, and checking them increases episodes of feeding tube occlusion, reduce the total volume of EN delivered, and take up RN time

Question 31

**If GRVs are checked, what are the ASPEN/SCCM recommendations?

Answer 31

**In the absence of other signs of intolerance (vomiting or abdominal distention), EN should not be held for GRVs of less than 500 mL.

Question 32

In what patient populations, is checking GRVs helpful?

Answer 32

Patients that are high risk for GI dysfunction, in the surgical ICU and the most severely ill patients

Question 33

What methods should be used routinely for checking GI function?

Answer 33

1. Passage of flatus and stool
2. Stool frequency and consistency
3. Physical exam to assess bowel sounds, abdominal girth, and abdominal radiographs

Question 34

What methods are used to assess for dehydration?

Answer 34

• Poor skin turgor
• Dry mucous membranes
• Elevated [BUN], [Cr], and [Na2+]

Question 35

What are causes for hyperglycemia in the ICU?

Answer 35

Causes are multifactorial and include:

• Increased release of counterregulatory hormones that stimulate gluconeogenesis
• Proinflammatory cytokines that result in IR
• Provision of steroid and adrenergic meds
• Excess dextrose admin via IV fluids and meds

Question 36

**What are SCCM/ASPEN guidelines for acceptable blood glucose control in hospitalized patients?

Answer 36

**140 - 180 mg/dL

BG levels should be checked every 4 - 6 hours for patients with diabetes OR in patients with BG over 180 mg/dL

Question 37

How should optimal BG control be achieved in the hospital setting?

Answer 37

Continuous insulin drip; hyperglycemia is not an indication to delay initiation of EN

Note: oral meds and SSI should not be used because they can delay the achievement of BG control and are associated with a higher incidence of renal dysfunction

Question 38

If an MD recommends switching the EN formula to a higher-fat content formula, what would you say?

Answer 38

It is not recommended because the higher fat content may delay gastric emptying, affecting tolerance and thereby limiting the ability to achieve goal volumes.

Question 39

If an MD notes serum albumin and prealbumin as indicators of nutrition status, what would you say?

Answer 39

They are now known as indicative of inflammatory status and not nutrition intake. No serum lab values indication nutrition status or adequacy of nutrition provision.

Question 40

should specialty / disease specific formulas be used in the critically ill

Answer 40

no

Question 41

EN formulas containing omega three fatty acids (immune modulating) can be recommended when

Answer 41

surgical care unit

Question 42

Symptoms of GI Intolerance during EN

Answer 42

abdominal distention, increased NGT output, high GRV’s over 250mL, decreased passage of stool, increased metabolic acidosis

Question 43

If a patient has prolonged NPO status the gut will atrophy loosening the tight junctions allowing pathogens to enter the blood circulation possibly causing sepsis. Therefor what is recommended

Answer 43

start early enteral nutrition within 24-48 hours of ICU admission

Question 44

Uses for MCT Oil

Answer 44

Fat malabsorption (impaired GI tract, IBD, chylous ascites, enteropathies, pancreatitis, SBS, intestinal resection)

Question 45

What are designer triglycerides that are chemically synthesized or genetically engineered containing more EPH and DHA which are more easily absorbed

Answer 45

Structured lipids

Question 46

Where are structured lipids used in the US

Answer 46

enteral nutrition formulas

Question 47

where are structured lipids used in Europe

Answer 47

parenteral nutrition

Question 48

Function of hydrolyzed EN formulas

Answer 48

peptide based (Di and Tri peptides) , used in impaired GI function so they are more readily absorbed

Question 49

formulas with arginine should not be used when

Answer 49

severe sepsis (is the pre cursor to nitrous oxide which can cause hemodynamic instability)

Question 50

EN formulas that contain arginine, EPA, DHA and glutamine

Answer 50

immune modulating formulas

Question 51

% water in 1 kcal/mL EN formulas

Answer 51

83% water

Question 52

% water in 1.2 kcal/mL EN formulas

Answer 52

80% water

Question 53

%water in 1.5 kcal/mL EN formulas

Answer 53

76-78% water

Question 54

% water in 2 kcal/mL EN formulas

Answer 54

70-75% water

Question 55

indications for nutrition support

Answer 55

oropharyngeal dysfunction

Question 56

use of PN _____ mortality in burn patients compared to EN

Answer 56

increases

Question 57

contraindications to enteral feeding

Answer 57

intractable nausea/vomiting
high output proximal fistula
acute necrotizing pancreatitis
ileus

Question 58

Are adult TF products lactose free

Answer 58

yes

Question 59

the majority of carbohydrates in EN formulas come from

Answer 59

hydrolyzed cornstarch

Question 60

when should branch chain amino acid EN formulas be used in hepatic encephalopathy

Answer 60

when severe encephalopathy persists after trial of lactulose/neomycin

Question 61

what percentage of water do 1kcal/mL EN formulas supply

Answer 61

75-85% water

Question 62

formulas made of free amino acids are _____ formulas

Answer 62

elemental

Question 63

elemental formulas are indicated in

Answer 63

short bowel syndrome

Question 64

enteral formulas that have intact macronutrient, require normal digestive/absorptive function

Answer 64

polymeric

Question 65

isotonic EN formulas are ___ free

Answer 65

fiber free

Question 66

low osmolarity (300 mOSm), fiber free, EN formula used for high risk intestinal ischemia 2/2 inadequate bowel function

Answer 66

isotonic formula

Question 67

formula with small peptides, free amino acids

Answer 67

hydrolyzed protein EN

Question 68

are broken down proteins/free amino acid EN formulas recommended for Chron’s remission

Answer 68

no, intact protein formulas

Question 69

are intact protein EN formulas okay to use in critically ill

Answer 69

yes

Question 70

EN formulas recommended for patients with inadequate enzyme release, short bowel syndrome or other malabsorption syndromes

Answer 70

peptide based EN formulas

Question 71

Phenylkeotnuria (PKU) is a metabolic disorder with a deficiency in the _____ enzyme

Answer 71

Phenylalanine Hydroxylase

Question 72

Phenylalanine Hydroxylase coverts phenylalanine to

Answer 72

tyrosine

Question 73

in PKU, this amino acid becomes essential so is added to PKU formulas

Answer 73

tyrosine

Question 74

what is the primary use for enteral nutrition

Answer 74

providing nutrition directly to patients who cannot or are unwilling to get adequate nutrition by mouth

Question 75

inadequate intake or expected intake for 7-14 days

critically ill patients, working gut, hemodynamic stability are recommended for _______ nutrition

Answer 75

enteral

Question 76

early nutrition in the ICU

Answer 76

start EN within 24-48 hours

Question 77

when should EN be started when not on the ICU

Answer 77

after 7-14 days in a well nourished patient who cannot meet nutrition needs by mouth orally

Question 78

typically, how long after PEG or PEJ placement, can EN feedings start

Answer 78

2 hours or per surgeon

Question 79

short term enteral feeding is considered how long

Answer 79

= 4 weeks

Question 80

long term enteral feeding is considered how long

Answer 80

> 4 weeks

Question 81

benefits of enteral feeding

Answer 81

immune function, prevents bacterial translocation, preserves gut permeability, decrease risk of infection, decrease length of stay decreases mortality

Question 82

contraindication to EN

Answer 82

expected duration of use <7-10 days in nourished patient, <5-7 days in malnourished patient, short bowel syndrome (<100-150 cm bowel), severe GI bleed, severe malabsorption, distal high output fistula, intractable N/V, paralytic ileus, mechanical obstruction

Question 83

Fermented Oligosaccharides (FOS) and inulin in En formulas help stimulate

Answer 83

good bacterial growth

Question 84

if a patient has gastroparesis, consider this EN formula to help with gastric emptyin

Answer 84

low fiber, peptide based/hydrolyzed

Question 85

this formula has 100% free amino acids

Answer 85

elemental formulas

Question 86

in adults, elemental formulas still contain allergens true or false

Answer 86

true (soy and milk protein)

Question 87

EN formula that is low in carbohydrate, high in fat and fiber

Answer 87

diabetic EN formula

Question 88

are diabetic EN formulas recommended for routine use

Answer 88

No

Question 89

only consider using renal formulas in AKI if

Answer 89

there are electrolyte abnormalities

Question 90

are renal EN formulas recommended for routine use

Answer 90

no

Question 91

renal formulas have high ____ and ___ which limits their use in post pyloric tubes

Answer 91

osmolarity/viscosity

Question 92

this type of EN formula is low in carbohydrate, high in omega 6 fatty acid

Answer 92

pulmonary EN formula

Question 93

this EN formula contains branched chain amino acids

Answer 93

hepatic EN formula

Question 94

are EN formulas with omega 3 fatty acids recommended for routine use in ARDS/ALI

Answer 94

no

Question 95

these EN formulas contain omega 3 fatty acids, glutamine, arginine, nucleotides and antixoidants

Answer 95

immune modulating EN formulas

Question 96

are immune modulating EN formulas recommended for routine use in the MICU

Answer 96

no

Question 97

why are immune modulating EN formulas contraindicated in septic patients

Answer 97

they contain arginine which is a precursor to nitrous oxide which can cause hemodynamic instability

Question 98

when are immune modulated EN formulas recommended

Answer 98

surgical ICU, TBI and peri operative trauma patients, post op patients

Question 99

types of modulars

Answer 99

protein (powder or liquid), carbohydrate powder, MCT oil for fat, soluble/insoluble fiber

Question 100

these type of schedule for EN feedings can be provided by syringe, gravity or the pump

Answer 100

intermittent

Question 101

type of feeding schedule where EN runs for 24 hours

Answer 101

continuous

Question 102

when is a pump recommended for EN provision

Answer 102

jejunal feedings

Question 103

in the critically ill what feeding method for EN is recommended

Answer 103

continuous

Question 104

how should an EN feeding be started and advanced in the ICU

Answer 104

start 10-40ml/hr advance 10-20mL q8-12 hours until goal

Question 105

when started on bolus feedings how should EN be started and advanced

Answer 105

60-120 mL per feedings then advance 60-120mL per feeding q8-12 hours

Question 106

bolus feeding is considered this schedule type of feeding

Answer 106

intermittent

Question 107

what should be written on the EN order

Answer 107

1. Name of the Formula
2. What type of tube will be used (PEG,PEJ etc)
3. What method of feeding (continuous, bolus)
4. What additives are needed
5. Extra safety measures (aspiration precautions)

Question 108

what is the best method to unclog a tube feed

Answer 108

water flushes and prevention

Question 109

should medications be mixed with enteral formula

Answer 109

no

Question 110

can creon or zenpepare be used to unclog a feeding tube

Answer 110

no because they are enterically coated

Question 111

what is the recommended enzyme for de clogging a tube feed

Answer 111

Viokace mixed with 324 mg of sodium bicarb or 1/8 teaspoon of baking soda mixed with 5 mL of water

Question 112

Viokace should be mixed with _____ to remove a TF clog

Answer 112

324 mg sodium bicarbonate

Question 113

Bionix

Answer 113

a feeding tube declogger that requires a trained professional to use. Only for gastrostomy or jejunostomy not naso or oral tubes

Question 114

what is the definition of diarrhea

Answer 114

2-3 liquid stools >250 grams per day

Question 115

high osmolarity medications or formulas, fiber, sorbitol are all possible causes of

Answer 115

diarrhea

Question 116

what is recommended for fiber when a patient is having diarrhea

Answer 116

add or remove fiber

Question 117

what are methods to reduce diarrhea in the enterally fed patient (in order)

Answer 117

1. Rule out infection
2. Reduce sorbitol containing meds (1st line)
3. Decrease TF rate
4. add or remove fiber

Question 118

Insoluble fiber ____ transit time by adding to fecal weight

Answer 118

increases (makes it longer)

Question 119

insoluble fiber works by

Answer 119

adding weight to stool

Question 120

When a patient is at risk for bowel ischemia fiber should

Answer 120

be avoided

Question 121

fermentable oligosacchardies that help the growth of bacteria are called

Answer 121

pre-biotics

Question 122

are routine use of pre-biotics recommended

Answer 122

not at this time

Question 123

what is fiber’s role in constipation

Answer 123

can increase BM frequency when baseline BMs are low

Question 124

ways to alleviate constipation in enterally fed patients

Answer 124

1. add water
2. increase physical activity
3. add fiber
4. try prune or pear juice flushes

Question 125

Likely the main cause of nausea and vomiting in EN patients is

Answer 125

delayed gastric emptying

Question 126

what can be done to help alleviate nausea/vomiting in EN patients

Answer 126

decrease TF rate, start pro kinetic, trial anti emetic

Question 127

dry skin, dry mucous membranes, constipation and skin tenting, increased heart rate, decreased blood pressure are signs of ____ in EN patients,

Answer 127

dehydration

Question 128

what is the best method for PEG or PEJ tube site care

Answer 128

clean with soap and water, keep open to air

Question 129

is swabbing the stoma of EN the best method to test for infection

Answer 129

no, other normal bacteria will be there

Question 130

what are possible signs of PEG tube site infection

Answer 130

fever, induration, redness, malaise

Question 131

what is recommended standards of care for patients with EN who are at risk for aspiration

Answer 131

1. Elevate head of bed >30-45 degrees
2. good oral care
3. continuous feeding
4. consider post pyloric feeding
5. don’t routinely check GRVs

Question 132

how should EN formulas be stored at _______ _____

Answer 132

room temperature

Question 133

once open sterile EN formulas can last ___ hours in the fridge

Answer 133

24 hours

Question 134

EN bags should only be used for

Answer 134

24 hours

Question 135

what is the hang time for sterile, open system EN formulas

Answer 135

12 hours (tetra packs)

Question 136

If powders are added to a sterile open system feeding, how long should the hang time be decreased from 12 hours

Answer 136

4 hours

Question 137

what is the hang time for powdered formulas

Answer 137

4 hours

Question 138

what is the hang time for sterile closed system EN feedings

Answer 138

24-48 hours

Question 139

what is the hang time for blenderized tube feeding

Answer 139

2 hours

Question 140

Case: a 25 year old F with traumatic brain injury s/p MVA. She is preparing to dc to rehab and still has an NG tube. The RDN recommends transitioning to intermittent feeding to mimic real meal times. The patient develops water diarrhea on day1 of intermittent feeding. What should be done first

Answer 140

obtain a chest x ray to verify that the tip of the tube has not migrated to the jejunum where a large volume feeding would cause diarrhea

Question 141

Indications for home EN feeding

Answer 141

motility disorder, malabsorption disorder, head/neck cancer, dysphagia, pancreatitis, obstruction, failure to thrive

Question 142

what makes a good EN candidate

Answer 142

1. patient/caregiver is able to administer the EN independent of care staff
2. pt has easy access to medical care follow up
3. safe home environment
4. adequate education

Question 143

what is involved in a safe home environment for EN

Answer 143

clean water, electricity, refrigeration, access to a phone, good lighting

Question 144

what is needed to document medical necessity (by the physician)

Answer 144

tube type
swallow eval
gastric emptying study
fat malabsorption

Question 145

for medicare how many days in considered permanent

Answer 145

90 days (3 months)

Question 146

in order to have medicare reimbursement what conditions are covered under non functioning gut or disease of the structures that permit food reaching the small bowel)

Answer 146

1. non functioning gut or disease of the structures that permit food reaching the small bowel
2. Dysphagia
3. Esophageal cancer with obstruction
4. Gastroparesis

Question 147

in order to have medicare reimbursement what conditions are covered under disease of the small bowel which impairs digestion / absorption of an oral diet

Answer 147

1. Small bowel disease/Chron’s

2. SOLE source of nutrition

Question 148

For medicare reimbursement what needs to be documented to be covered for a non standard formula

Answer 148

severe diarrhea trialing both fiber containing and fiber free formulas

feeding <750 kcal or >2,000 kcal/day to maintain appropriate weight

Question 149

What is not covered under medicare for enteral nutrition

Answer 149

1. anorexia from mood/psych disorder
2. end stage disease
3. weight loss
4. failure to thrive
5. malnutrition in the absence of functional impairment

Question 150

HME provider stands for

Answer 150

Home Medical Equipment proivder

Question 151

which foundation provides donations to help support costs of EN

Answer 151

Oley foundation

Question 152

What can food stamps be used to buy

Answer 152

oral supplements

Question 153

what should be on the education checklist for EN feedings

Answer 153

1. how to order supplies
2. goals of HEN for the patient
3. specifics about the tubes, replacement and care
4. feeding schedule, administration, formula , water medication’s
5. troubleshooting issues
6. Hangtime/storage
7. Support for home resources (Oley foundation, feeding tube awareness foundation)

Question 154

What is the best method to assess patient’s grasp of education in the home enteral nutrition session

Answer 154

teach back

Question 155

when providing tube feeds by cans, you can improve success by having _____ number of cans

Answer 155

rounded (ex. 2 instead of 1.5)

Question 156

after starting HEN of oftenshould follow up occur

Answer 156

every 3 months

Question 157

for successful HEN, it best to have a _____ approach

Answer 157

multidisciplinary approach

Question 158

DME stands for

Answer 158

Durable Medical Equipment company (Supplies pumps, materials and formulas)

Question 159

A 70 year old male with dysphagia s/p stroke is now discharged home after 1 month of a rehab stay. When is the ideal time to provide HEN education

Answer 159

throughout the rehabilitation stay

Question 160

this type of feeding tube is placed at skin level, good for cosmetic appearance, more comfortable for active individuals

Answer 160

low profile tube

Question 161

short term feeding tubes (< 4 weeks)

Answer 161

nasogastric, orogastric tube

Question 162

small bore feeding tubes are recommended for _____ while large bore/stiff tubes are recommended for _____

Answer 162

feeding, suction

Question 163

Nasogastric tubes are contraindicated in

Answer 163

head/neck/esophageal pathology, injury preventing safe insertion

Question 164

what is the gold standard for checking NGT placement

Answer 164

chest x-ray

Question 165

how are NGTs measured before insertion

Answer 165

NEMU: nose to earlobe to mid umbilicus

Question 166

Nasal Enteric Tubes tips end

Answer 166

the distal stomach towards the pylorous

Question 167

In order to help place nasal enteric tubes which terminate by the pylorus of the stomach, what can aid in the placement

Answer 167

prokinetics, IV erythromycin 200-500 mg

Question 168

This type of tube is placed in the nasal cavity, terminates past the ligament of Treitz

Answer 168

Nasojejunal tube

Question 169

What is the most reliable method to place NJ tubes

Answer 169

endoscopy or fluroscopy

Question 170

feeding tubes that are placed endoscopically require

Answer 170

sedation

Question 171

How long will tube feed be needed to consider percutaneous placement

Answer 171

> 4-6 weeks, long term

Question 172

are testing of coagulation parameters (INR etc./ platelets) required for patients undergoing enterostomy tube placements

Answer 172

no; unless they are on anticoagulation medications, have excessive bleeding or on recent abx

Question 173

patients who have had excessive bleeding, recent abx, and on anticoagulation meds may need this checked before percutaneous tube feeding placement

Answer 173

INR/platelets

Question 174

patients who are at thromboembolic risk are on clopidrel/thienopyridines should have these meds held ___ to ___ days before percutaneous placement

Answer 174

5-7 days

Question 175

how long should warfarin be held before PEG placement. What medication can they be bridged with in the mean time

Answer 175

5 days, short acting heparin

Question 176

obstruction proximal to the GI tract, ascites, gastric varicies, active head/neck cancer, and morbid obesity are contraindications to ____ placement

Answer 176

PEG tube placement

Question 177

impaired gastric motility, pancreatitis/pancreatic surgery and stomach decompression are recommended to have these types of percutaneous feeding tubes placed

Answer 177

PEJ

Question 178

Fluoroscopic percutaneous tube placement must be done where

Answer 178

in a radiological suite

Question 179

how long after placement can percutanous tubes be removed to ensure stoma maturity

Answer 179

1-2 weeks or 4-6 in extra tenuous patients

Question 180

if PEG tubes or PEJ tubes are removed to early what are the risks

Answer 180

bowel contents/stomach contents can leak into the peritoneum

Question 181

how should stomas be routinely cleaned

Answer 181

warm water, mild soap

Question 182

Are routine use of antibiotics recommended for PEG tube site care

Answer 182

no

Question 183

what is the best way to prevent tube feed clogging

Answer 183

Adequate flushing of at least 30mL of water

Question 184

other ways of preventing tube clogging

Answer 184

don’t check GRV’s too often, avoid very concentrated formulas, don’t mix meds with EN formula

Question 185

what type of pills are more likely to promote TF clogs

Answer 185

crushed pills

Question 186

medications should be given all at once or separately to prevent TF clogs

Answer 186

SEPERATELY with flushes in between

Question 187

complications of NG tube placement

Answer 187

Epistaxis, aspiration, pneumothorax

Question 188

reducing narcotics, low fiber/fat formulas, room temp enteral formulas, pro kinetic agent, small volume feedings and anti emetics are all solutions to this complication of tube feeding

Answer 188

nausea

Question 189

abdominal distention during tube feeding can result from

Answer 189

ileus, obstruction, ascites, rapid formula administration of very cold formulas/high fiber

Question 190

weight loss, steatorrhea, diarrhea, vitamin/mineral deficiencies, and glossitis could be signs/symptoms of _____ during enteral feeding

Answer 190

malabsroption

Question 191

measuring fecal fat, serum citrulline, or examine intestinal transit can rule out/ identify _______of the gut

Answer 191

maldigestion

Question 192

what is the most common reported GI side effect with Enteral Nutrition

Answer 192

diarrhea

Question 193

medicatiosn high in sorbitol (amantadine, doxycycline, lasix, metoclopramide, isonazid and tylenol liquid meds) can cause

Answer 193

diarrhea

Question 194

what items should be evaluated when a patient on enteral feeding experiences diarrhea

Answer 194

1. Review medications for sorbitol or pro kinetic agents

2. Check for bacterial causes (CDiff)

Question 195

If medications/infectious causes of diarrhea are ruled out, what can be added to the EN regimen to reduce diarrhea

Answer 195

Soluble fiber and or anti diarrheal meds

Question 196

fiber modulars have a high risk of ______ en tubes

Answer 196

clogging

Question 197

what is the PRIMARY intervention to treat EN associated diarrhea

Answer 197

use fiber containing formula

Question 198

what is the LAST RESORT intervention for EN associated diarrhea

Answer 198

switch to a peptide based formula

Question 199

this test helps identify Small Intestinal Bacterial Overgrowth (SIBO)

Answer 199

hydrogen breath test

Question 200

EN formulas are at highest risk of contamination when

Answer 200

they are mixed, diluted or reconstituted (powdered)

Question 201

EN formulas that are at the lowest risk of contamination

Answer 201

sterile or closed systems

Question 202

liquid formula that is provided via syringe or poured into a bag and delivered by gravity or pump is considered a _______ system

Answer 202

open system

Question 203

what is the hang time of open systems (syringe, or pouring into a bag)

Answer 203

4-12 hours

Question 204

this type of EN formulas is powdered or formula with added modulars provided by gravity or pump

Answer 204

reconstituted

Question 205

reconstituted enteral feedings can only hang for a maximum of

Answer 205

4 hours

Question 206

powdered EN formula should be mixed with _____ water

Answer 206

sterile

Question 207

this type of EN formula system are contained in pre filled sterile bottles with spike or screw tops

Answer 207

closed system

Question 208

closed system enteral feedings can be hung for

Answer 208

24-48 hours

Question 209

what is the proper technique for preparation of formula

Answer 209

hand washing, gloves, aseptic technique, clean , maximum barrier precautions

Question 210

formulas should be used _____ after opening or being reconstitution with water

Answer 210

immediately

Question 211

if you have left over formula from a sterile bottle how long can it be stored in the fridge

Answer 211

24-48 hours

Question 212

A sterile tube feeding formula is running at 25mL/hr for 8 hours. 200 mL of formula is left over after the feeding bag is filled where should the formula go

Answer 212

in the refrigerator

Question 213

how often should TF bags be changed

Answer 213

every 24 hours

Question 214

how can checking GRVs cause contamination

Answer 214

introducing pathogenic microorganisms when pulling back stomach contents, infecting the TF hub/port

Question 215

Implementing Prevention Policies for EN

Answer 215

1. visually inspect each TF bottle for expiration date/damage
2. use proper hand washing technique, wear clean gloves
3. Prepare the formula in a clean area
4. wipe flip top bottles with isopropyl alcohol
5. Assess the TF formula for separation, thickening or curdling
6. use sterile water to prepare powdered formulas
7. Minimize frequent disconnections and reconnections of the tubes
8. keep equipment dry and clean

Question 216

dehydration, excessive or inadequate fiber, and fluid restriction cause ________

Answer 216

constipation

Question 217

if a patient is on a fluid restriction but suffering from constipation on tube feeding what can be used

Answer 217

stool softener

Question 218

increasing fiber in constipation propels waste through the colon

Answer 218

constipation

Question 219

Inadequate _____ can result in infrequent bowel movements and cause significant buidldup in the colon

Answer 219

fiber

Question 220

firm collection of stool in the distal colon where liquid stool will seep around an impaction

Answer 220

obstipation

Question 221

a rare TF complication associated with fiber modular that are formed in the stomach

Answer 221

bezoar

Question 222

sings of EN Intolerance

Answer 222

abdominal distention, nausea, vomiting

Question 223

dyspnea, wheezing, hypoxia, anxiety, fever, leukocytosis or new/progressing infiltrates are signs os

Answer 223

aspiration PNA

Question 224

is blue dye recommended

Answer 224

NOOOOOOO

Question 225

if GRV’s ARE checked when should tube feeding be held

Answer 225

when >500 mL with vomiting or diarrhea for more than 48 hours

Question 226

are checking GRVs routinely used to monitor ICU patients on EN

Answer 226

No

Question 227

what can be used for oral care in the ICU to prevent aspiration of tube feeding

Answer 227

chlorhexidine

Question 228

what populations are at risk for refeeding syndrome

Answer 228

malnourishment, diarrhea, high output fistula, ETOH intake, poorly controlled DM, anorexia nervosa, IBD low birth weight, prematurity

Question 229

if an enterally fed and at risk for refeeding syndrome EN should only provide _____ of the goal on Day 1 with attention to energy contribution from ______ and advance to goal within ____ to ____ days pending elytes and clincal status

Answer 229

25%, 3-5 days

Question 230

tube fed patients are at risk for ____ because EN formulas don’t contain total fluid needed and require additional water flushes

Answer 230

dehydration

Question 231

dry mouth, eyes and lips, light headedness when standing, headache, fatigue, heat intolerance dark urine, orthostatic hypotension, increased heart rate, poor skin turgor and sunken eyes are signs of

Answer 231

dehydration

Question 232

an increased BUN:Cr ratio of 20:1 can indicate ________ when there are no renal issues

Answer 232

dehydration

Question 233

typical urine output

Answer 233

0.5 to 2 mL/kg/hr

Question 234

1 kg of weight = ______ liter of fluid

Answer 234

1

Question 235

when a patient has a fever increase water provision by ____% per degree Celcius above 37.8 degrees

Answer 235

12%

Question 236

this type of nasal feeding tube allows the most digestion as the nutrients mix with gastric juices

Answer 236

nasogastric

Question 237

this type of tubing for PEGS hangs out

Answer 237

standard profile

Question 238

during PEG placement, an endoscope goes down the _______, a _____ is shone through at the placement site in the stomach and the _____ is pushed through the cutaneous layer.

Answer 238

esophagus
light
bolster

Question 239

what type of feeding is not recommended for jejunal feedings

Answer 239

bolus

Question 240

bolus-ing tube feed into the jejunum can cause

Answer 240

vomiting, excessive diarrhea

Question 241

an incorrectly positioned feeding tube, where the balloon or silicone cuff is inside the abdominal wall while the bolster is on the outside indicates

Answer 241

Buried Bumper Syndrome

Question 242

pain at a PEG tube site and weight gain can indicate this complication

Answer 242

Buried Bumper Syndrome

Question 243

when a tube feeding formula is accidentally connected to a ventilator or IV this considered a ____ event

Answer 243

sentinel

Question 244

ENFIT was developed by this company

Answer 244

GEDSA Global Enteral Device Supply Association

Question 245

ENIFT tubes prevent ________

Answer 245

enteral tubing misconnections

Question 246

A patient gets an NG tube placed and is immediately started on a standard formulas of 10mL/hr. The patient develops coughing, an inability to speak and decreased O2 saturations

Answer 246

rule out lung placement of NG tube with a CXR

Question 247

bleeding, peritonitis, or colo-cutaneous/colo-gastric fistulas are complications of

Answer 247

PEG placement

Question 248

dislodgement of this type of tube requires immediate replacement because the tract can close quickly

Answer 248

dislodged jejunotomy tube

Question 249

the dislodgement of a jejunostomy tube needs to be replaced by

Answer 249

a physician at the hospital as it requires radiographic verification with contrast medium to confirm placement

Question 250

what is a common contributor to the occlusion of small bore feeding tubes

Answer 250

aspiration for measurement of gastric residuals

Question 251

ways to ensure patency to avoid clogged feeding tubes

Answer 251

use proper TF administration
flush 15-30mL before/after each med
use digestive enzymes with sodium bicarb
use a mechaical de clogging device

Question 252

the primary cause of diarrhea in an enterally fed patient are

Answer 252

medications containing sorbitol elixirs

Question 253

a majority of enteral formulas are ___ free so patients with lactose intolerant do not have to worry about using them

Answer 253

lactose

Question 254

what is the most common cause of diarrhea

Answer 254

bowel impaction/obstipation

Question 255

the passage or secretion of fluid around a stool impaction that can cause loose stool/diarrhea

Answer 255

obstipation

Question 256

GI mucosal edema 2/2 hypo-albuminemia may result in

Answer 256

severe diarrhea

Question 257

the most common cause of diarrhea in EN formula fed patients

Answer 257

sorbitol containing meds/elixirs as a flavor enhancement

Question 258

if a patient is experiencing significant diarrhea, this type of fiber can help decrease diarrhea

Answer 258

soluble fiber: will absorb fluid

Question 259

An elderly nursing home resident w/ a hx of constipation with a new PEG, how can you ensure that they do not become constipatied

Answer 259

provide 1kcal/mL of formula with fiber and adequate water

Question 260

an enterally fed patient suffering from constipation may benefit from additional

Answer 260

water/water flushes

Question 261

causes of constipation in EN patients

Answer 261

dehydration, long-term fiber free feedings, prolonged bed rest, prolonged bed rest, narcotic use

Question 262

65yo who is bed bound s/p CVA with dysphagia on 1.5 cal/mL formula at 50mL/hr, is 70 inches tall, 150 lbs and gets 60mL of water 5x/day. He develops constipation. How do you improve bowel function . What are the patient’s fluid needs

Answer 262

1. 1mL/kcal (1800mL) or 30ml/kg (2045mL)
2. Water flushes provide 300mL total a day and the TF formula provides about900mL of water (75% H2O in 1.5 kcal formula). This is a total of 1650mL of water which is below his needs.
3. You would need to increase free water flushes for extra hydration

Question 263

methods to help with gastroparesis in TF patients

Answer 263

1. discontinue narcotics (slows GI transit)
2. Try lower fat/lower fiber formula (fat/fiber slows GI emptying)
3. Administer TF at room temperature
4. administer jejunual feedings

Question 264

what is the most likely etiology of gastric emptying in diabetics

Answer 264

hyperglycemia

Question 265

enteral formulas used for diabetic gastroparesis are low in

Answer 265

fat and fiber and are isotonic

Question 266

rapid bolus infusion, feeding tube migration, excessive feeding volume, gastroparesis are all possible causes of ___ in EN patients

Answer 266

nausea/vomiting

Question 267

what should be done when an EN patient experiences nausea and vomiting

Answer 267

1. treat nausea/vomiting with regaln/zofran

2. decrease TF rate or volume

Question 268

A potentially fatal condition caused by a feeding regimen given through a tube that provides too little water and too much protein in the diet is called

Answer 268

tube feeding syndrome

Question 269

azotemia, hypernatremia and dehydration are symptoms or signs of

Answer 269

tube feeding syndrome

Question 270

what is the etiology of tube feeding syndrome

Answer 270

high protein tube feeding without enough water causing a high renal solute load so nitrogen builds up in the blood stream

Question 271

how can tube feeding syndrome be prevented

Answer 271

provide adequate fluid and don’t use a protein load over 1.5 g/kg body weight unless warranted (burns, CRRT)

Question 272

granulation/scar tissue can form within the feeding tube tracts and grow out onto the surface of the skin usually where

Answer 272

the exit site

Question 273

how is hypergranulation around a PEG tube site prevented

Answer 273

1. keep PEG tube exit site dry and clean
2. Makes sure the tube is stabilized and doesn’t move more than 1/4 of an inch from the stoma
3. non occlusive dressings
4. add triamcinolone cream

Question 274

risk factors for buried bumper syndrome

Answer 274

weight gain especially in the abdomen

Question 275

Increased weight gain and increased abdominal girth puts extra pressure on the bolster of a PEG tube increasing the risk for pressure necrosis and ulceration can lead to ___ ___ __

Answer 275

buried bumper syndrome

Question 276

pain and pressure on the inside of the stomach, pain, bleeding, obstruction, cellulitis or abscess around the PEG site

Answer 276

buried bumper syndrome

Question 277

buried bumper syndrome can be life threatening as

Answer 277

it can cause tube feeding formula to leak into the abdomen

Question 278

what starting a continuous feeding start with ___ strength at ___ to __ mL/hr and gradually increase toward _____

Answer 278

full strength
15-20mL/hr
goal

Question 279

why is it NOT recommended to dilute enteral formulas

Answer 279

can cause diarrhea or microbial contamination
reduces osmolality
decreases total calories and decreased protein

Question 280

when chyme enters the small intestine, bile salts, pancreatic enzymes, bicarb and water are released in increasing amounts to make EN formula isotonic is called

Answer 280

autotonicity

Question 281

what is the reason for early EN

Answer 281

to attenuate the rapid depletion of nutrient stores after metabolic stress or to maintain immune function

Question 282

when should EN be avoided

Answer 282

not fully volume resuscitated
not hemodynamically stable
mesenteric profusion is not restored

Question 283

what method of tube feeding delivery is preferred on the ICU

Answer 283

pump assisted

Question 284

this type of enteral feeding methods is easy to control the rate and volume, establishes better tolerance, has fewer gastric complaints, and possibly reduces the risk for aspiration

Answer 284

continuous pump assisted

Question 285

what types of feeding methods are allowed for gastric feedings

Answer 285

bolus, intermittent, or continuous feeding

Question 286

this type of enteral feeding method provides 200-300mL of formula over 30-60 minutes every 4-6 hours

Answer 286

intermittent (gravity, bolus)

Question 287

this method of administering enteral feedings provides EN over 8-20 hours during the day or night depending on the tolerance of the patient, allowing the patient time off the pump

Answer 287

cycled EN feedings

Question 288

if a patient on a continuous EN formula will be transitioning to PO intake and EN at the same time. What can help mitigate full ness during day time feeding

Answer 288

cycling at night

Question 289

if a patient is bolused into the jejunum with a PEJ or NJ what would be the consequences

Answer 289

diarrhea, bloating

Question 290

when is it appropriate to start transitioning a patient from a cycled EN feeding to an oral diet

Answer 290

has normal GI function
not ventilated
tolerating a polymeric formula for at least 1-2 days
when EEN meets at least 60% of needs/clinical judgement

Question 291

most enteral tubes are made out of this material

Answer 291

polyurethane

Question 292

what should be performed to assess feeding tube placement prior to the initiation of enteral feeding

Answer 292

chest x-ray to confirm placement

Question 293

for a post-op patient with a proximal small intestinal enterocutaneous fistula who is to be enterally fed, what is considered to be the ideal location for placement of the feeding tube in relation to the fistula site

Answer 293

distal to the fistula

Question 294

before placing a PEG tube, is testing of coagulation parameters and platelets still recommended. When at all should they be tested.

Answer 294

1. No not recommended routinely
2. If a patient has a concern for abnormal coagulation d/t anticoagulant meds, history of excessive bleeding or recent ANTIBIOTIC USE

Question 295

what is the most reliable method to placing nasojenunal tubes

Answer 295

endoscopy

fluoroscopy

Question 296

If a patient has recently been on antibiotics what should be checked/tested fore PEG or PEJ placement

Answer 296

1. INR, coagulation parameters

Question 297

Patients on coumadin, have a high risk of bleeding or are recently on antibiotics are at high risk of PEG/PEJ placement according to

Answer 297

The American Society of Gastrointestinal Endoscopy Guidelines

Question 298

clopidrel/thienopyridines (inhibits platelet aggregation) should be held ___ to ___ days before PEG/PEJ placement. If not what should be given to promote vasoconstriction in patients with high thromboembolic risk

Answer 298

5-7 days

epinephrine

Question 299

how long should warfarin be held before PEG placement

Answer 299

5 days

Question 300

patients who normally take warfarin at high risk for bleeding should be bridged with short acting _______ before PEG placement

Answer 300

heparin

Question 301

_____ are given prophylactically when PEG tubes are placed to decrease peristomal infection when using endoscopy

Answer 301

antibiotics

Question 302

the most common method for PEG placement is

Answer 302

Ponsky/Pull method

Question 303

what is the soonest a percutaneous tube can be removed after placement

Answer 303

1-2 weeks after the stoma has matured

Question 304

most clinicians wait until ___to___ weeks to remove a percutaneous tube, especially for patients with immunosuppression, steroid use, obesity or poor wound healing

Answer 304

4-6 weeks

Question 305

what happens when a percutaneous tube is removed too early

Answer 305

the stomach/bowel can fall away from the abdominal wall and bowel contents can leak into the peritoneum

Question 306

a percutaneous tube should be replaced

Answer 306

endoscopically, interventional radiology or surgery

Question 307

a standard profile or low profile percutaneous tube can be exchanged _______ unless it is a direct gastrojejunostomy or jejunostomy

Answer 307

at the bedside

Question 308

if a patient suddenly develops pain, gastric leakage and reddened/ulcerated skin soon after percutaneous tube feeding placement what should be done

Answer 308

1. verify the placement of the tube to make sure there is no peritoneal leakage
2. Replace tube and confirm correct location with fluoroscopy or endoscopy after replacement

Question 309

if a percutaneous feeding tube is mispositioned over time it can lead to ____ if not treated

Answer 309

necrotizing fasciitis

Question 310

what is one of the best ways to prevent aspiration PNA in patients with PEG tubes/NPO

Answer 310

good oral hygeine

Question 311

what is the best method to clean a percutaneous tube around the skin

Answer 311

warm water
mild soap
rinse and dry

Question 312

is routine use of antibiotic ointments or hydrogen peroxide recommended to prevent infection around a stoma

Answer 312

No; should not be preventative

Question 313

what are methods to prevent feeding tube clogging

Answer 313

1. adequate flushing with meds/feedings
2. don’t over check GRV’s
3. avoid high protein/high fiber formulas or use larger bore tubes

Question 314

in order to reduce the chance of a feeding tube to clog what is essential

Answer 314

flushing protocol compliance

Question 315

each patient should be evaluated in conjunction with a ___ to determine the best way to deliver a medication to a tube fed patient

Answer 315

Pharmacist

Question 316

meds should be given ____ to decrease risk of clogs and be ___ before and after each administration

Answer 316

separately

flushed

Question 317

what can be used to prevent tube dislodgement

Answer 317

a bridle

Question 318

cracking, breaking or kinking of a feeding tube is consider a

Answer 318

tube malfunction

Question 319

obstruction of physiological sinus drainage by a naso-enteric tube is a complication of what

Answer 319

sinusitis

Question 320

vomiting in minimally responsive patients may increase the risk of

Answer 320

aspiration PNA

Question 321

to gastric residual volumes correlate with tube feeding tolerance

Answer 321

no

Question 322

ileus, obstruction, obstipation, ascites , diarrheal illness, rapid formula admin or infusion of very cold formulas can can all cause

Answer 322

bloating/abd distention

Question 323

impaired breakdown of nutrients into the absorbable forms are called

Answer 323

maldigestion

Question 324

how is maldigestion tested for

Answer 324

fecal fat assessment
lactose tolerance test
schilling test for B12 absorption
small bowel biopsy

Question 325

Celiac disease, Chron’s disease, diverticulosis, radiation enteritis, enteric fistula, short gut and SIBO are all possible causes for

Answer 325

maldigestion

Question 326

if providing a high sorbitol medication in an enteral feeding what can be provided to reduce irritation of the gut

Answer 326

give with at least 30-60mL of water

Question 327

is intact protein recommended for starting patients on tube feedings

Answer 327

yes

Question 328

____ might be the most tolerable form of protein in EN formulas on the critically ill patient

Answer 328

polypeptides

Question 329

a patient can become ____ intolerant after illness, especially when transitioning to an oral diet because most EN formulas are ____ free. Try a ___ restricted diet to reduce diarrhea.

Answer 329

lactose intolerant, lactose free, lactose restricted

Question 330

what are the first steps in managing diarrhea in an enterally tube fed patient

Answer 330

1. rule out infection/inflammatory causes
2. rule out fecal impaction/obstipation
3. Identify sorbitol containing medications

Question 331

if diarrhea continues in an enterally fed patient what medication can be given to slow down the diarrhea

Answer 331

anti-diarrheal agent (loperamide, octreotide)

Question 332

if a patient’s abdomen (who is getting tube fed) becomes distended, tympanic or painful what should be done

Answer 332

1. stop the tube feed and contact the MD to evaluate

Question 333

if diarrhea is not related to a medical or surgical reason, and has not had a BM in 5 days assess for

Answer 333

1. regular narcotic use, stool impaction, fluid provision

Question 334

if a patient is not on cathartic medications, doesn’t have a surgical reason and not on sorbitol medications what should be assessed with diarrhea

Answer 334

C Difficile

Question 335

a patient develops 4-5 water stools a day. what should the RD evaluate.

Answer 335

1. is the patient getting high sorbitol or hypertonic solutions
2. are they on a pro-kinetic, antibiotic

Question 336

To manage diarrhea in a tube fed patient (not due to medications) ____ fiber can be used in a modular or specific formula. However this can clog tubes.

Answer 336

soluble fiber

Question 337

if a patient has been on prolonged antibiotics and having diarrhea, what should be tested

Answer 337

C Difficile

Question 338

what is the primary EN intervention when a patient has diarrhea (not due to meds, infection, sorbitol)

Answer 338

use a fiber containing formula

Question 339

what is the last resort type of formula when a patient has diarrhea (not due to meds, infection, sorbitol)

Answer 339

peptide based formulas

Question 340

accumulation of excess waste in the colon is known as

Answer 340

constipation

Question 341

if constipation is suspected, what should be the following steps

Answer 341

1. check for SBO, obstruction or ileus

Question 342

prolonged use of ____ can cause tachyphylaxis and should not be used for constipation

Answer 342

sennakot

Question 343

firm collection of stool in the distal colon where liquid stool will seep around an impaction

Answer 343

impaction

Question 344

who are at risk for fecal impaction

Answer 344

older adults, bed bound

Question 345

who are at risk for intestinal ischemia

Answer 345

neonates
critically ill
immunosuppressed

Question 346

what precautions are used to prevent intestinal ischemia in enteral nutrition

Answer 346

1. delay EN until fluid resuscitated
2. avoid EN during profound hypotension/hypovolemia
3. use isotonic, fiber free EN formula
4. ongoing monitoring of abdomen, MAPs

Question 347

what is the most invasive method of NGT placement

Answer 347

endoscopic, requires placement of a large instrument along with the feeding tube

Question 348

what is used for pharmacologic stimulation of tube feeding placement

Answer 348

pro-kinetic to stimulate gastric peristalsis

Question 349

the external bumper used in the placement of PEG/PEJ to hold the stomach or small bowel in place against the abdominal wall

Answer 349

T-fastener

Question 350

how long are t-fasteners kept in place to allow formation of a stoma tract

Answer 350

10-14 days

Question 351

air insufflation, auscultation and pH aspirates to check TF placement are not recommended as

Answer 351

lead to false positives and can lead to tube placement into the tracheobronchial tree

Question 352

to decrease the risk of the feeding tube being placed into the airway during NG placement is to have the patient

Answer 352

bend their head forward and tuck their chin to their chest

Question 353

the most successful way to place a trans pyloric feeding tube is

Answer 353

fluoroscopy

Question 354

a 75 year old female with dementia and history of aspiration would best benefit from this tube

Answer 354

PEJ; decreased risk of aspiration and long term

Question 355

contraindications to PEJ placement

Answer 355

end jejunostomy, short bowel syndrome if only the jejunum remains

Question 356

What is the maximum hang time for closed-system enteral formulas?

Answer 356

48 hours

Question 357

What are the fluid needs for an adult over the age of 65?

Answer 357

30 mL/day with a minimum of 1500 mL

Question 358

What percent water are standard enteral formulas?

Answer 358

~84%

Question 359

What are the benefits of early enteral feeding in critically ill patients?

Answer 359

• Decreases translocation of gut bacteria
• Reduces atrophy of intestinal villae
• Reduces risk for infectious complications.

It does not increase intestinal permeability.

Question 360

What are the 2 most important factors in assessing the adequacy and efficacy of enteral feedings in pregnancy?

Answer 360

1. Maternal weight gain

2. Fetal growth

Question 361

(TRUE/FALSE)

There is a strong correlation between infant birth weight and maternal weight.

Answer 361

TRUE

Question 362

Why is serum albumin not recommended for assessing the adequacy and efficacy of EN during pregnancy?

Answer 362

Serum albumin is not recommended due to diluational effects associated with normal plasma expansion and alterations in plasma protein production.

Question 363

Lactose is a common ingredient in which type of enteral formula?

Answer 363

Standard infant formula

Lactose is used to mimic the carbohydrate found in human milk.

Question 364

What EN formula is appropriate for patients with chyle leaks? Why?

Answer 364

Elemental

Goal of nutrition mgmt:

• Reduce the quantity and duration of chyle loss
• Determine patient’s response to an elemental, low-fat diet before initiating PN

Question 365

What are 3 important parameters for predicting tolerance of EN in patients with pancreatitis?

Answer 365

1. APACHE II score (disease severity; most important)
2. Duration of NPO (Greater than 6 days have shown poor tolerance)
3. Increasing abdominal pain

Question 366

(TRUE/FALSE)

Triglyceride level is an appropriate parameter for EN tolerance in patients with pancreatitis.

Answer 366

FALSE.

Serum TG levels are used to measure tolerance of PN, not EN

Question 367

When should EN be initiated?

How long should it last?

Answer 367

When patients are expected to (or have) not received adequate oral intake x 7 - 14 days.

Duration of EN should not be less than 5 to 7 days in the malnourished patient or 7 to 9 days in the adequately nourished patient.

Question 368

(TRUE/FALSE)

It is safe to provide EN in patients with open abdomen.

Answer 368

TRUE.

In patients requiring open abdomen mgmt after laparatomy, PN should be deferred until EN is not tolerated x 7 or more days.

PN should be indicated in patients with high output mid-jejunal fistula, intractable obstipation and vomiting and short bowel syndrome.

Question 369

Why would placement of a jejunostomy feeding tube NOT be beneficial for patient’s with short bowel syndrome?

What is recommended instead?

Answer 369

Infusion of EN into the jejunum will result in increased stool output and decreased absorption.

Slow continuous infusion into the stomach is recommended to maximize absorption and increase intestinal transit time.

Question 370

What is the best intervention to assist with the appropriate placement of an NG tube in an alert patient?

Answer 370

Elevate the HOB to a sitting position, having the patient flex their head slightly forward once the tube tip is in the posterior nostril.

Having the patient swallow small sips of water may prevent respiratory misplacement.

IV metoclopramide is a prokinetic agent that may assist with transpyloric tube passage.

Question 371

(TRUE/FALSE)

Bedside electromagnetic imaging systems have shown greater than 90% success with placement.

Answer 371

TRUE.

Weighted tube tips are the LEAST likely to facilitate transpyloric placement of an NG tube.

Question 372

What is the primary advantage of a direct PEJ (percutaneous endoscopic placed jejunal tube) VERSUS PEG-J (percutaneous endoscopic transgastric-placed jejunal tube)?

Answer 372

Reduced incidence of migration or flipping back into the stomach in the PEJ.

Although gastric outlet obstruction may occur may in the PEG-J method, that is NOT the primary advantage of using PEJ.

Bleeding risk is no different

The ability to place PEG-J depends on the skill of the endoscopist.

Question 373

What characteristic of enteral formulas is the MOST likely to increase splanchnic blood flow in a critically ill patient?

Answer 373

Research has shown that blood flow to the bowel is maximized with the use of HIGH FAT formulas over high CHO formulas.

An isotonic, fiber-free formula is ideal for patients at high risk for intestinal ischemia as adequate bowel perfusion is necessary for tolerance of high fiber, high osmolarity feedings.

Question 374

What two interventions reduce the risk of aspiration with EN?

Answer 374

1. Elevate HOB to 30-45 degrees
2. Oral hygiene

No benefit to holding the TF during brief periods of supine positioning or elevated gastric residuals.

Question 375

What is the effect of alpha-2 adrenergic agonist meds in EN?

Answer 375

Alpha-2 adrenergic agonists, such as clonidine, have been shown to have significant antimotility effects and often prolong instead of reducing intestinal transit time.

Question 376

(TRUE/FALSE)

Metoprolol administration requires changing TF schedules.

Answer 376

FALSE, does NOT.

Question 377

(TRUE/FALSE)

The bioavailability of warfarin, phenytoin, carbamazepine, and fluoroquinolones, such as ciprofloxacin, may be altered with EN and the EN feeding is often held for up to 2 hours, before and after administration to reduce interactions.

Answer 377

TRUE, but there is controversy surrounding holding TF

Many practitioners do not recommend holding TF around medication administration due to suboptimal nutrition delivery and lack of evidence. Many will justify continuing EN around medications that could potentially interact, and for adjustment of meds to help maintain therapeutic serum drug levels.

Question 378

(TRUE/FALSE)

An acidic juice such as OJ can reduce the risk of microencapsulated beads/pellets sticking to the tube.

Answer 378

TRUE.

The tube should be flushed with 30 mL water before and after administration of the drug-juice mixture to avoid physical interactions between the acidic juice and the EN formulation.

Mixing drugs with carbonated beverages may be problematic due to the physical drug-nutrient interaction with the EN formulation.

The use of water or an oral electrolyte solution to administer granules may cause them to become sticky and adhere to the tube, thereby increasing the risk for feeding tube occlusion.

Question 379

What is the hang time for blenderized formulas?

Answer 379

2 to 8 hours depending on if it’s homemade or commercial

Question 380

What is the hang time for reconstituted enteral formulas?

Answer 380

Hang-time for powdered formula is limited to 4 hours (at room temperature)

Hang-time for canned or bottled sterile, liquid formulas is 8 hours.

Must be prepared aseptically and by trained personnel

Question 381

What is the hang time for closed system EN?

Answer 381

24 to 48 hours, depending on the connection set.

Question 382

What is the best method to assess protein requirement and adequacy?

Answer 382

The gold standard for assessing adequacy of protein intake in the hospitalized patient is NITROGEN OUTPUT.

-Derived using UUN and requires a 24-hour urine collection.

N balance = N intake (intake in nutrition support divided by 6.25) - N output (UUN x urinary volume / 100 + 20% urinary urea losses + 2g)

Example: EN provides 136g protein

N balance = 21.8g - [16+3.2(20%) +2] = 0.6 or N equilibrium

Question 383

(TRUE/FALSE)

Elemental and semi-elemental formulas are designed for patients with GI dysfunction, including patients with known malabsorptive disorders or those having difficulty absorbing or digesting standard polymeric formulas.

Answer 383

TRUE.

Polymeric formulas may also have more benefits than elemental formulas in patients with intestinal failure as these formulas are more isotonic and may better enhance intestinal adaptation.

Question 384

Immune-modulating EN formulas should be reserved for which patients?

Answer 384

Trauma, TBI and, surgical ICU patients.

Question 385

(TRUE/FALSE)

Immune-modulating EN formulas are contraindicated in septic patients.

Answer 385

TRUE.

Due to adverse effects are seen with arginine supplementation in these individuals.

Question 386

(TRUE/FALSE)

Immune-modulating EN formulas are recommended for routine use in the medical ICU.

Answer 386

FALSE, are NOT recommended

Question 387

Which of the following are modular products?

 Safflower oil
Protein
Glucose
Selenium
MCT oil
Fiber
Glutamine
Cholecalciferol

Answer 387

MCT oil, glucose, fiber, and protein

Modular products are commonly used to fortify enteral nutrition regimes or meals served
-Are typically single-nutrient products and are available for use in addition to the selected oral or enteral products.

Question 388

(TRUE/FALSE)

There is believed to be an increased ratio of AAA (aromatic AA) to BCAAs in patients experiencing hepatic encephalopathy.

Answer 388

TRUE, therefore, the use of EN enriched with BCAAs may benefit patients with refractory encephalopathy.

But the use of these hepatic formulas be limited to patients with encephalopathy that is unresponsive to standard medical therapy (lactulose, non-absorbed abx)

Question 389

Why may EN be contraindicated in the early post-transplant period with hematopoietic cell transplants?

Answer 389

Because of potential mucosal toxicities related to the conditioning regime.

GI toxicities such as: N/V/D/delayed gastric emptying seen in the 2-3 weeks post-stem cell transplant may preclude EN.

Question 390

Which type of medications can be crushed for administration via EN tube?

Answer 390

Only immediate-release tablets

Question 391

(TRUE/FALSE)

Modified release dosage (such as XL, XR, SR, CD) are inappropriate crush and give via EN tube because crushing these dosage forms destroys their modified releasing properties.

Answer 391

TRUE. This may lead to an excessive dose of the drug being released at one time (instead of slowly over a longer period of time), which can lead to adverse effects and has even been reported as a cause of death.

Question 392

what are major risk factors for aspiration in critically ill patients

Answer 392

1. decreased levels of consciousness
2. previous history of aspiration
3. vomiting
4. tracheal intubation
5. neuromuscular disease
6. persistent high gastric residual volume
7. prolonged supine positioning
8. large diameter feeding tube

Question 393

what is the most appropriate management of hyperagranulation around a PEG tube site

Answer 393

cauterize with silver nitrate

Question 394

_______ forms within the tract of a PEG tube and may grow on the surface of the skin. It is a source of moisture underneath the bolster causing breakdown of the skin

Answer 394

granulation tissue

Question 395

A tube feeding schedule where formula is provided as 240mL administered over 45 mins 5x/day is known as a __________

Answer 395

intermittent schedule

Question 396

Tube feeding provided in a volume between 240-480mL given over 45minutes several times a day with or without a pump is called _____ feeding

Answer 396

intermittent feeding

Question 397

What is the benefit of using an electromagnetic replacement device for NGT placement?

Answer 397

it provides a 3 dimensional localization, displayed in real life. A receiver is placed on the patient at the xiphoid process, therefore the magnet follows the tip placement relative to the LES, not the pylorus.

Question 398

In a patient with a newly placed gastrostomy or jejunostomy tube, observation of which conditions at the tube exit site would signal a possible peristomal infection?

Answer 398

foul smelling drainage

Question 399

The most common complication soon after PEG or PEJ placement is a

Answer 399

peristomal infection

Question 400

what type of feeding schedule would be the most appropriate for a critically ill patient with poorly controlled blood glucose

Answer 400

continuous (consistency stabilizes blood sugars)

Question 401

Continuous tube feeding is most appropriate in the critically ill and poorly controlled diabetic TF patient as intermittent schedules may cause fluctuations in blood glucose concentrations, placing patients at risk for ______ or ______ complications

Answer 401

hypo or hyperglycemia

Question 402

A terminally ill patient at home on hospice complains of nausea during enteral feedings. A decision is made to discontinue the enteral feeding because

Answer 402

1. EN feeding and hydration don’t always ensure comfort
2. During starvation the body produces ketones which are euphoric
3. The most common symptom when nutrition/hydration are withheld is dry mouth, which is alleviated with good oral mouth care
4. IV hydration in the terminally ill patient can raise the risk of patient discomfort and respiratory distress

Question 403

The most common symptom when withholding hydration or nutrition from a terminally ill patient would be _____ and can be alleviated by ________

Answer 403

dry mouth

good oral mouth care

Question 404

One method of minimizing the complications associated with refeeding syndrome is to initiate an electrolyte replacement protocol before nutrition therapy begins. This should also be done on patients that

Answer 404

are not considered to be at risk to also be added on the protocol

Question 405

when refeeding, electrolytes should be replete via which route

Answer 405

IV, oral or feeding tube depending on appropriateness

Question 406

when a patient is at risk for refeeding syndrome, feedings should ________ be delayed but instead __________

Answer 406

don’t delay nutrition feedings

initiate slowly, advance slowly per electrolyte levels and clinical response

Question 407

Bacterial contamination during enteral feeding can originate from the patients throat, stomach, lungs, feeding equipment, and retrograde contamination from the patient’s own

Answer 407

secretions

Question 408

the longer an enteral product is hung the _______ the chance of bacterial contamination

Answer 408

higher

Question 409

A male patient suffered from a stroke 2 wks ago and has significant dysphagia. An isotonic EN formula has been infusing continuously at a goal rate for 2 days, along with an ordered 30mL water flush per hour. The pt begins to complain of bloating and his abd becomes mildly distended to 4 cm from baseline. He denies nausea, bad cramping or abd pain. His last 2 gastric residual volumes were measured at 100mL. What is the best strategy to reduce his symptoms?

Answer 409

check when his last bowel movement was and if the patient is found to be constipated, initiate a bowel regimen

Question 410

abdominal distention from enteral feeding can be caused by _______ administration from bolus schedules, _________ solutions, pain medications that slow ______, tube migration from the stomach to the _________, cold temperature formula inadequate fluid causing constipation, and fat/fiber/lactose intolerance.

Answer 410

1. rapid administration
2. hyper-osmolar solutions
3. peristalsis

Question 411

Only hold a tube feeding if a patient’s abdominal girth has extended beyond ____ to ___ cm

Answer 411

8-10

Question 412

Patients who are alert and cooperative are at the ____ risk of pulmonary injury from small bore feeding tube misplacement

Answer 412

lowest risk

Question 413

Oral or nasogastric feeding tubes used for EN should only be indicated for use less than ____ weeks

Answer 413

4 weeks

Question 414

Placement of feeding tubes is complicated in uncooperative patients with anatomic abnormalities and critically ill patients in which ______ is inhibited

Answer 414

swallowing

Question 415

a patient with oral cancer who has gained 10 lbs since starting home bolus EN feedings via gastrostomy tube complains of pain and pressure on the “inside of his stomach.” but no redness or drainage at the exterior gastrostomy site. What is the most appropriate response for the clinician?

Answer 415

refer the patient to the gastroenterologist or enterostomal nurse

Question 416

a new occurrence of pain at or near the tube feeding site of a patient should be promptly evaluated by

Answer 416

the patient’s GI doctor or enterostomal nurse

Question 417

Constipation in the enterally fed patient may be associated with

Answer 417

obstruction
lack of adequate hydration
prolonged best rest / lack of activity
long term fiber free feedings
narcotics

Question 418

what is most likely the cause of watery diarrhea and bloating in the enterally fed adult

Answer 418

sorbitol content of liquid medications

Question 419

An enterally fed patient reports nausea and vomiting. If delayed gastric emptying is the suspected cause, what can be done to improve the patient’s symptoms

Answer 419

decrease or discontinue narcotic meds
use low fat. low fiber formulas
administer TF at room temp
decrease the rate or volume of the feeding

Question 420

the initiation of enteral tube feeding should be delayed in the ICU when the patient is _________, and not ______ to decrease the risk of intestinal ischemia

Answer 420

hemodynamically unstable

fully volume resuscitated

Question 421

evidence of bowel sounds is _______ required prior to the initiation of EN

Answer 421

NOT required

Question 422

Patients at risk for refeeding syndrome should _____ delay EN

Answer 422

NOT delay

Question 423

how should EN feeding be initiated and advanced in the hospitalized patient

Answer 423

use a full strength formula, start at 10-40mL/hr and advance to goal rate within 1-2 days

Question 424

while a patient is receiving SLP therapy, oral foods are provided during daytime hours. To meet the patient’s nutrition requirements, polymeric tube feeding is required during the night at a rate of 75mL/hr over 10 hours. This night feeding is an example of

Answer 424

cyclic feeding

Question 425

Patients who are on TF via pump and are initiated on oral foods during the day would likely benefit from ______ feedings schedules

Answer 425

overnight cycle feedings

Question 426

what type of insulin should be used when initiating EN in a hospitalized diabetic patient?

Answer 426

regular insulin

Question 427

An 82 year old female s/p CVA with dysphagia and subsequent PEG placement weighing 45 kg is initiated on tube feeds which provide 1500 kcal, 63 g of protein/L. The team added a modular protein supplement providing 15 grams additional protein a day. She is discharging home and will be taken care of by family. During the tube feeding education what is important to discuss with the family to prevent tube feeding syndrome

Answer 427

the importance of providing adequate free water daily

Question 428

What is tube feeding syndrome

Answer 428

the use of high protein tube feeding without adequate fluids. The kidneys are inefficiently able to excrete the solute load and can cause azotemia, hypernatremia and dehydration.

Question 429

most enteral formulas designed for oral consumption are made up primarily of

Answer 429

carbohydrates (40-60% total kcals from carbs)

Question 430

______ in enteral formulas designed for oral consumption provide palatability

Answer 430

sucrose

Question 431

blue dye is ______________ recommended for the detection of aspiration of enteral formula 2/2 low sensitivity, several cases of system toxicity and is removed by the FDA

Answer 431

NOT

Question 432

which enteral feeding method provides 240mL of formula via a syringe over as few as 4-10 minutes, 3-6 times a day

Answer 432

bolus

Question 433

bolus feedings mimic

Answer 433

normal feeding schedules

Question 434

what type of feeding delivery method is most appropriate for patients with a jejunostomy

Answer 434

continuous pump

Question 435

_______ feedings via pump minimize diarrhea and abdominal bloating

Answer 435

continuous

Question 436

which type of enteral nutrition delivery is preferred for critically ill patients

Answer 436

continuous

Question 437

why is continuous enteral tube feeding the most appropriate for critically ill patients

Answer 437

controls the rate and volume
better EN tolerance
decreased aspiration risk

Question 438

which of the following is a best practice recommendation in EN formula safety

Answer 438

change the EN feeding administration set every 24 hours with open systems

Question 439

EN that is mixed, reconstituted or diluted should be done in _________ to decrease the risk of contamination

Answer 439

a sterile, centralized location

Question 440

Only ___ to ___ hours of formula should be poured into an open set

Answer 440

8-12 hours

Question 441

canned, ready-to-use formula hang times should be a maximum of

Answer 441

12 hours

Question 442

closed EN formula can be safely used for ______ hours after opening

Answer 442

24-48 hours

Question 443

__________ formulas should be immediately refrigerated after preparation, discarded within 24 hours of not being used and should not be held at room temperature for longer than 4 hours

Answer 443

powdered

Question 444

use of purified water vs tap water does what

Answer 444

decreases risk of bacterial contamination

Question 445

what are the benefits of closed enteral feeding systems

Answer 445

decreased risk of microbial contamination
minimal manipulation needed
long hang times of 24-48 hours
requires less nursing time

Question 446

when transitioning from enteral to oral feeding, tube feeding may be discontinued when adequacy of oral intake meets at least _________ needs

Answer 446

66% of estimated needs (2/3 to 3/4)

Question 447

what information should always appear on the label of an enteral feeding product given to a hospitalized patient

Answer 447

patient identification
product name
administration method
route of delivery
access device
date and time the formula was prepared/hung/expires

Question 448

when administering multiple medications via enteral feeding tubes, medications should be

Answer 448

administered separately and flushed with 15-30mL of water before and after administration

Question 449

enteric-coated, controlled release and sustained release medications should not be ______ and given via feeding tube

Answer 449

crushed

Question 450

what type of feeding tube requires immediate replacement if it becomes dislodged as the tract can close very quickly

Answer 450

jejunostomy

Question 451

replacement of a jejunostomy tube requires

Answer 451

radiographic verification with contrast medium

Question 452

the first replacement of a gastrostomy or PEG tube should be done

Answer 452

by the physician who inserted the tube, after that it is appropriate for trained nurses to replace them

Question 453

Nasogastric or nasoduodenal tubes can be replaced by who

Answer 453

doctors, physicians assistances, nurse practitioner’s or appropriately trained healthcare providers

Question 454

what type of formulas are most likely to occlude a feeding tube

Answer 454

calorie dense

high fiber

Question 455

what can be done to assist with maintaining feeding tube patency in the adult patient

Answer 455

flush the feeding tube with 30mL of water every 4 hours during continuous feeding, and also flush after measuring GRVs

Question 456

change short term feeding tubes (NG,NJ,ND)every ____ to ___ weeks

Answer 456

4-6 weeks

Question 457

which of the following is not a research based method to restore patency to clogged feeding tubes

Answer 457

cranberry juice

Question 458

what 3 methods are used to restore patency to clogged feeding tubes?

Answer 458

water flush
mechanical de-clogging devices
pancreatic enzymes mixed with NaBicarb

Question 459

you get a consult for a patient on EN with abdominal distention, nausea and vomiting. Monitoring of GRV’s have been ordered. What intervention can be utilized to prevent feeding tube occlusion associated with GRV assessment in an adult patient

Answer 459

flush the feeding tube with 30mL of water after GRV assessment

Question 460

The Society of Critical Care Medicine and ASPEN 2016 guidelines suggest that ________ should not be used as part of routine care to monitor EN tolerance

Answer 460

gastric residual volumes

Question 461

what methods have been proven effective in decreasing the risk of aspiration associated with enteral tube feeding in adult patients

Answer 461

good oral care BID
motility agents when TF intolerance
post pyloric tube when the patient is at high risk

Question 462

what is most likely to improve tolerance of enteral feeding in a patient who is post op and documented with high gastric residual volumes, receiving bolus tube feedings

Answer 462

switch to continuous tube feedings

Question 463

recovery of gastric emptying may be slower than the return of _____ motility in the post op patient

Answer 463

small bowel

Question 464

continuous feedings is the preferred method in the _______

Answer 464

small bowel

Question 465

`what is the primary cause of oozing stools in a tube fed patient

Answer 465

fecal impaction

Question 466

______ can be manifested by symptoms of diarrhea with constipation

Answer 466

impaction

Question 467

a home enteral nutrition patient recently treated for pneumonia is noted to have new onset diarrhea. What should be the first intervention be?

Answer 467

obtain a CDiff culture especially if the patient was recently on abx

Question 468

A patient with short bowel and end-jejunostomy requires the use of an oral rehydration solution to help prevent dehydration. What best describes the preferred composition of the ORS?

Answer 468

an iso-osmolar solution such as juice diluted with 50% water, should be made up of glucose to promote salt and water absorption and 90-120mEq/L of sodium

Question 469

Glucose in oral rehydration solutions serves what function

Answer 469

to promote salt and water absorption

Question 470

why are commercial sports drinks not good oral rehydration solutions

Answer 470

they contain much more glucose and not enough sodium

Question 471

what is the optimal concentration of an oral rehydration solution for patients with short bowel syndrome to promote jejunal absorption

Answer 471

90-120mEq/L

Question 472

in critically ill patients getting early EN, which is the most likely to increase success in achieving goal feeding rates?

Answer 472

volume based EN feeding protocols

Question 473

what is the maximum hang time for human breast milk

Answer 473

4 hours

Question 474

Your patient is showing outward signs of tube feeding intolerance including nausea and abdominal distention. The nurse checks gastric residuals and the last 3 measurements are 265mL, 250mL and 330mL. What is the most appropriate recommendation

Answer 474

consider adding promotility agent

Question 475

the largest payer of home enteral and PN is

Answer 475

Medicare

Question 476

education materials for home EN/PN should be at a ____ level

Answer 476

6-8th grade level

Question 477

what should be evaluated on a home care provider performance improvement plan

Answer 477

hospital re admit rate (also, mortality rate, customer satisfaction, complications, problem reporting/resolution)

Question 478

benefits of a home nutrition support team

Answer 478

earlier transition to PO or EN, avoids multiple lab draws, improved coordination of care, more psychosocial support, earlier identification of potential problems and deficiencies

Question 479

a non-profit organization for education and support that is free to all home PN or EN patients

Answer 479

Oley Foundation

Question 480

what are the benefits of a nutrition support support group

Answer 480

increased quality of life, decreased depression, decreased incidence of catheter related sepsis

Question 481

how often should electrolytes be monitored in nutrition support

Answer 481

Initially: weekly until clinically stable

Question 482

What makes a patient a good candidate for home EN

Answer 482

physical & emotional well being, willingness to go home, adequate storage pace, electricity, running water, phone in the home, patient support/support network, back up battery for powered infusion pump

Question 483

Medicare: in order to be covered for a tube feeding pump at home you must have

Answer 483

nausea/vomiting, GERD, gastroparesis, dumping syndrome

Question 484

in order to be covered for home enteral feeding ____ must not be possible

Answer 484

PO intake

Question 485

according to medicare, permanence of EN or PN is defined as > ____ days

Answer 485

90 days

Question 486

when an anatomic or motility disorder will interfere with oral intake for > 90 days, EN will be covered. True or False

Answer 486

True

Question 487

for an enterally fed home patient, a pump will be covered if

Answer 487

intolerance to bolus or gravity feeding is demonstrated

Question 488

Third Party insurance payers are the ____ likely to pay for EN formulas because they equate to the cost of a grocery bill

Answer 488

third party

Question 489

the 3 most important monitoring for HEN patients who are stable are

Answer 489

weight, I/O and bowel function

Question 490

if a PEG tube dislodges after the tract matures (>6 weeks) a replacement tube can be

Answer 490

reinserted and surgery is not required

Question 491

if a PEG tube dislodges that has an immature tract, within ___ hours a dilator can be used to open the tract IN THE HOSPITAL NOT AT HOME

Answer 491

12

Question 492

what is the best way to ensure the patient is performing proper tube feeding technique

Answer 492

return demonstration

Question 493

To ensure the best adherence to feeding and improved psychosocial health of a tube fed patient their tube feeding schedule should be

Answer 493

integrated into the patient/family’s way of living and should simulate normal meal times

Question 494

in a stable home EN patient, it would be most appropriate to routinely monitor

Answer 494

weight, intake/output, bowel fx

Question 495

enteral feeding should be incorporated into the patient’s/families

Answer 495

lifestyle, mimic normal meal times

Question 496

what is encouraged of family members of an enterally fed patient at home

Answer 496

participation, dinner table socializing

Question 497

a home tube fed patient’s administration schedule should mimic

Answer 497

normal meal times

Question 498

patient education materials should be at the ___ to ____ grade level

Answer 498

5th to 6th grade level

Question 499

the best way to to know the patient/family’s understanding of EN delivery is

Answer 499

return demonstration/ teach back

Question 500

an active process where the patient can demonstrate themselves and verbalize the process is called

Answer 500

teach back/ return demonstration

Question 501

Teach Back/Return demonstration helps the patient/family get accurate _______, verify ______ and reinforce new home care ________

Answer 501

information
understanding
skills

Question 502

the maximum hang time for an open enteral system IN THE HOME SETTING is

Answer 502

12 hours

Question 503

the maximum hang time for a closed system in the HOME setting is

Answer 503

24-48 hours

Question 504

the best way to care for the skin around a feeding tube is

Answer 504

mild soap and water, rinse and keep dry thoroughly, clean under the external bolster

Question 505

when are dressings recommended for PEG tubes

Answer 505

only if there is drainage

Question 506

the home care improvement plan for an enterally fed tube feeding patient measures ________ in the home tube feeding setting

Answer 506

outcomes

Question 507

what NEEDS to be included in the home care improvement plan for home enterally fed patients

Answer 507

1. hospital re admits
2. complications
3. patient/family satisfaction
4. problem reporting/resolution

Question 508

Under the Centers for Medicare and Medicaid Prosthetic Device Act, hone enteral nutrition patients (HEN) are only covered if they meet the criteria for permanent disease of the structures that ________________ or disease of the small bowel that impairs. WITH these 3 documented indicators

Answer 508

1. permit the food to reach the small bowel
2. digestion/absorption of a PO diet
3. test of performance documented by MD
4. statement of permanence (90 days)
5. statement of needing to maintain weight/strength not possible by taking in oral nutrition supplements
6. serum albumin <3.4 g/dL , fecal fat test
7. weight loss >10% >/= 3 months

Question 509

In enteral nutrition discharge instructions the following needs to be documented. Name of the _______, total ______, route of _______, care of the ________, product hang time, stability at room temp, inspection of the product, expiration dates , _____ prevention, what to do when you _______, phone number for the home care company and proper_____

Answer 509

1. name of the formula
2. total daily volume needed
3. route of administration
4. care of the enteral access device
5. infection prevention
6. run out of supplies
7. storage

Question 510

the most common complication associated with PEG tube placement is ____ which can occur within days to months

Answer 510

peristomal infection

Question 511

examples of Medicare coverage part B conditions

Answer 511

obstruction 2/2 head/neck cancer
motility disorders
severe dysphagia

Question 512

which conditions are not covered by medicare for home EN

Answer 512

anorexia, malnutrition, nausea

Question 513

Medicare reimbursement for nutrition education by an RD is only covered for

Answer 513

diabetes
renal disease (pre dialysis)
kidney transplant

Question 514

managed care / private insurance companies usually use ______ criteria for HPN coverage

Answer 514

medicare criteria

Question 515

managed care/private insurance companies usually require _________ and medical _____ and sole source of ______ in order to cover EN

Answer 515

pre authorization
medical necessity
sole source of nutrition

Question 516

how often initially should electrolytes, glucose, BUN, Cr, Mag, Phos be monitored

Answer 516

weekly for 4 weeks or until clinically stable

Question 517

what type of venous access devices are indicated for home PN use

Answer 517

PICC lines (Hickman)
Implanted Ports
Tunneled CVCs

Question 518

a permanent ____ must be placed before discharging home with HPN

Answer 518

venous access device (central)

Question 519

upon initiation of home PN, initial lab data should be obtained when

Answer 519

prior to starting home PN

Question 520

the patient/training policies for home PN should address

Answer 520

education
training
evaluation of the patient/caregiver competency

Question 521

home infusion companies are responsible for the delivery of

Answer 521

1. nutrition products
2. supplies
3. nursing care
4. formula delivery
5. equipment delivery

Question 522

assessing of micronutrient status in HPN patients requires thorough ______

Answer 522

symptom observation

Question 523

copper deficiency masks _____deficiency making it difficult to assess home PN patients

Answer 523

B12

Question 524

Hypermagnesemia results from ______ in HPN patients

Answer 524

commercial trace element preparation

Question 525

manganese is almost fully excreted by the ________

Answer 525

hepatobiliary system (bile)

Question 526

try to decrease the dose of manganese in patients on HPN with

Answer 526

hepatobiliary disease or liver disease

Question 527

who are at risk for a manganese toxicity

Answer 527

long term PN over 30 days with obstruction of the biliary duct

Question 528

when there is a toxicity of manganese with inability to excrete it through the bile, it can deposit in the ______ especially with IV manganese

Answer 528

brain

Question 529

what is the BEST way to detect manganese levels

Answer 529

whole blood manganese

Question 530

what is the best indicator for chromium deficiency

Answer 530

there is NO known reliable indicator of chromium status

Question 531

what are the roles of chromium

Answer 531

1. potentiates the action of insulin

2. plays a role in glucose, protein and lipid metabolism

Question 532

which populations are at risk for chromium deficiency

Answer 532

1. pregnancy

2. Type 2 DM

Question 533

if a patient is hyperglycemic, give ______ supplementation and see if the blood glucose resolves

Answer 533

chromium

Question 534

what are some causes of zinc deficiency

Answer 534

inadequate intake, decreased absorption, increased losses, increased demand

Question 535

primary symptoms of zinc deficiency

Answer 535

loss of taste, altered smell, rash, alopecia, gonadal hypofunction, night blindness

Question 536

every HPN patient should get ____ daily unless there is a toxicity / potential for toxicity or national shortage

Answer 536

micronutrients

Question 537

whenever a patient has a nutrient omitted what should be done

Answer 537

monitor for deficiency or toxicity that can develop over time

Question 538

are lab values always the best indicators for normal micronutrient status

Answer 538

NO

Question 539

normal lab values of micronutrients can give a false ______

Answer 539

sense of security

Question 540

failure to monitor which long term micronutrient can result in toxicities of these micronutrients in PN: zinc, manganese, folate or molybdenum

Answer 540

manganese

Question 541

hypermanganesemia can occur in all ____ patients regardless of liver function

Answer 541

long term PN patients

Question 542

PN contains these potential toxic elements from an ASPEN 2009 review

Answer 542

manganese, copper, chromium

Question 543

in the 2012 ASPEN recommendations, there was a recommended decrease of these trace elements

Answer 543

manganese and copper

Question 544

symptoms of manganese toxicity

Answer 544

headache, Parkinson’s like abnormalities

Question 545

Case: A malnourished patient with metastatic ovarian cancer is diagnosed with inoperable, partial SBO. She is taking in small amounts of a full liquid diet by mouth but is unable to take enough nutrition to maintain her weight. She has lost 12% of her body weight in the past 2 months. According to current Medicare guidelines the patient’s HPN will be covered under which of the following circumstances

Answer 545

1. the medical record must document failure of EN feeding tube or explain why it is not an option
2. it is critical to document a non functional GI tract

Question 546

diagnosis of a SBO alone is _____ qualifying for HPN

Answer 546

Not

Question 547

Large volume, small volume, pharmacy bulk PN components must be labeled with the amount of ______ anticipated to be in the product when the product _________

Answer 547

aluminum, expires

Question 548

the amount of aluminum on PN labels are about ____________ than what is actually in the PN bag of an individual patient

Answer 548

10 times more

Question 549

pharmacies are not require to list _____ content of each individual patient’s PN bag

Answer 549

aluminum

Question 550

symptoms of aluminum toxicity

Answer 550

neurological, hepatic, hematologic, skeletal muscle

Sx are non specific, non sensitive, can include some metabolic bone disease but is not the primary symptom

Question 551

the most practical way to manage micronutrients in long term PN patients is to

Answer 551

perform micronutrient assessment every 6 months including nutrient intake assessment, assessment for potential losses, medications/surgical history and a nutrition focused physical exam

Question 552

what are the causes of nausea and vomiting in long term EN patients

Answer 552

rapid EN infusion, gastric outlet obstruction from tube migration, excessive feeding volume, gastroparesis

Question 553

how is nausea and vomiting prevented in home EN patients

Answer 553

1. decrease TF rate/volume of an EN infusion of N/V occurs

Question 554

many third party payors (insurance companies) equate the cost of EN formulas to the cost of _____ and DON’T cover the expense

Answer 554

groceries

Question 555

if a patient cannot afford their formula, what are their options

Answer 555

1. work with an RD to find an alternative

2. there are non profit/indigent care programs to help

Question 556

EN formula may be covered under Medicare Part _____ and is usually only covered to about ____%. Patients with supplemental ______ may have the rest of the 20% covered.

Answer 556

Medicare Part B
20%
Supplemental insurance

Question 557

Home blenderized EN formulations should be discarded after _____ hours at home. Their hang time should be ____ hours.

Answer 557

Discard after 24 hours

hang time 4 hours

Question 558

which non profit organization is a great resource for home PN/EN patients

Answer 558

Association of GI motility Disorders

Question 559

a 69 year old male on a continuous, high-protein, high fiber tube feeding is running at 65mL/hr via a PEG. The TF was selected to assist with wound healing and diarrhea. The tube feeding is stopped every 6 hours , residuals are checked and the tube is flushed with 30mL of water. The patient is provided liquid medication via the PEG tube 2 times a day. The tube now seems occluded, why?

Answer 559

inadequate flushing

Question 560

the agency that regulates medical foods

Answer 560

the Food and Drug Administration (FDA)

Question 561

when should blue dye/blue food coloring be used in enteral tubes

Answer 561

NEVER

Question 562

what is not a nursing responsibility for monitoring jejunal tube feeding

Answer 562

measurement of residuals

Question 563

how can clogging of a feeding tube be prevented when checking residuals

Answer 563

flush the tube with 20-30 mL of water before checking a GRV to prevent clogging

Question 564

which patients are at risk for formula related contamination

Answer 564

neonates, critically ill, immunosuppressed, compromised gastric acid microbial barrier

Question 565

what are the 3 chances of contamination in EN formulas

Answer 565

storage
preparation
administration

Question 566

which type of Enteral Feeding has the lowest chances of contamination

Answer 566

sterile/closed system feedings

Question 567

which type of EN formula has the highest risk of contamination

Answer 567

mixing, dilution, reconstitution (powder)

Question 568

hang time for open systems

Answer 568

4-12 hours

Question 569

hang time for reconstituted formulas

Answer 569

4 hours, room temperature

Question 570

powdered enteral formulas are ____ sterilized

Answer 570

NOT

Question 571

___ water should be used to reconstitute powdered formula

Answer 571

sterile

Question 572

closed enteral systems can hang for ____ hours

Answer 572

24-48 hours

Question 573

formulas should be used ____ after opening which reconstitution with ____ water

Answer 573

immediately, sterile

Question 574

what should be referenced for recommended room temperature and hang time of specific formulas

Answer 574

manufacturer recommendations

Question 575

should a blender be used to mix powders

Answer 575

no, high risk of contamination

Question 576

clean the lids of enteral feeding products with ____ and dry

Answer 576

isopropyl alcohol

Question 577

how often should feeding bags be changed

Answer 577

every 24 hours

Question 578

when material from the lungs, stomach, and throat back up into the feeding tube, where they can proliferate and be re-infused in greater numbers is considered _____ contamination

Answer 578

retrograde

Question 579

most gravity drips have a ____ that decreases the risk of retrograde contamination

Answer 579

drip chamber

Question 580

checking ____ can also lead to contamination of enteral feeding by pulling back gastric contents and infecting the tube feed hub

Answer 580

gastric residuals

Question 581

what is one example of prevention policy for enteral feeding to reduce chance of contamination

Answer 581

enteral quality control programs/institutional protocols

Question 582

what is another example of prevention of EN contamination

Answer 582

define the process for receiving, distributing, storing, preparing, handling and administering EN

Question 583

To ensure safety during EN feedings, visually inspect each TF bottle for ___ and ___

Answer 583

damage

expiration date

Question 584

use proper _____ before feeding administration, and formula handling

Answer 584

hand washing/clean gloves

Question 585

flip top enteral feeding cans should be wiped with _______

Answer 585

isopropyl alcohol

Question 586

visually inspect EN formulas for

Answer 586

separation, thickening, clumping or curdling

Question 587

inhalation of material into the airway is known as

Answer 587

aspiration

Question 588

aspiration PNA can be caused when _____are in the wrong place or inhaled ____ contents

Answer 588

feeding tubes , gastric contents

Question 589

asymptomatic aspiration of saliva is called

Answer 589

silent aspiration

Question 590

dyspnea, wheezing, frothy/purulent sputum, cyanosis, anxiety, fever, tachycardia, rhonchi/rales, leukocytosis, leukopenia or a new / progressing infiltrate are symptoms of

Answer 590

aspiration pneumonia

Question 591

when aspiration occurs from a ventilator it is known as

Answer 591

ventilator associated PNA

Question 592

_____ is one of the most feared complications of EN and can lead to acute pulmonary pathology

Answer 592

aspiration PNA

Question 593

patients with dysphagia may aspirate saliva regardless of enteral feedings, true or false

Answer 593

true

Question 594

what are the steps to reduce aspiration risk during enteral feeding

Answer 594

1. elevated HOB 30-45 degrees
2. sit patient upright or reverse Trendelenburg position
3. good oral care BID with chlorhexidine
4. continuous tube feeding,
5. minimal sedation, suction prior to lying down,

Question 595

to decrease risk of aspiration check GRV’s every ___ hours if they are part of your hospital protocol. Start _____ in setting of elevated GRV’s in the critically ill and use ___ trees for actions depending on the GRV

Answer 595

4 hours
pro-kinetic
decision

Question 596

per ASPEN, GRV’s should ____ be used routinely to monitor ICU patients with enteral nutrition

Answer 596

NOT

Question 597

if your ICU still uses GRVs, avoid holding EN for GRVs < ____mL in the absence of other signs of feeding intolerance

Answer 597

500mL

Question 598

what methods should be used to check TF placement to decrease the risk of aspiration PNA and tube feeding

Answer 598

1. check visible tube length

2. routinely check CXR especially if migration is suspected

Question 599

to avoid hypertonic dehydration in EN what should be monitored

Answer 599

daily fluid
I/O
daily body weight
serum electrolytes
urine specific gravity
BUN/Cr raio
enteral/IV fluid provision

Question 600

excessive fluid intake, rapid feeding, catabolism of LBM tissue with potassium loss, cardiac insufficiencyy/renal/hepatic insufficiency/refeeding syndrome are all causes of

Answer 600

overhydration

Question 601

if a patient is experiencing overhydration during enteral feeding , what can be done/monitored

Answer 601

I/O
body weight/fluid status
check aldosterone (increases Na retention)
diuretic therapy

Question 602

refeeding syndrome, catabolic stress, high ADH/aldosterone, diuretics, diarrhea/NGT loss, metabolic alkalosis, insulin and dilution can all cause _____

Answer 602

hypokalemia

Question 603

if hypercapnia from overfeeding is suspected during enteral feeding what can be done

Answer 603

1. lower phosphorous
2. measure EEN with IC
   provide balance of CHO, fat and protein

Question 604

if a patient on EN develops low levels of serum zinc what can be done

Answer 604

supplement zinc in EN

Question 605

per ASPEN when EN is being provided in a patient suspected to be at risk for refeeding syndrome provide ____% of energy goal on Day 1 with attention to energy contribution from ____then cautiously advance toward energy goal within ____ to ___ days pending clinical status/electrolyte levels.

Answer 605

25% on day 1
dextrose from IV
3-5 days

Question 606

hyperglycemia is more common in EN Or PN

Answer 606

PN

Question 607

when a patient on Enteral Nutrition experiences hyperglycemia what can be done

Answer 607

1. use EN formula high in fat/fiber
2. manage with insulin
3. advance TF slowly toward goal

Question 608

a BUN/Cr ration over > can indicate dehydration

Answer 608

20:1

Question 609

a patient with renal failure/malnutrition with a BUN of 100 and Cr of 1 with a ratio of 100:1 may still be _____

Answer 609

adequately hydrated

Question 610

typical urine output range

Answer 610

0.5-2 mL/kg/hour

Question 611

1 liter of fluid = ___ kg of weight

Answer 611

1

Question 612

Describe the overall benefits of using enteral nutrition

Answer 612

Helps maintain the functional integrity of the gut
Promotes efficient nutrient utilization
Reduces the risk of cholecystitis by ensuring release of cholecystokinin with the presence of nutrients in the small bowel
Luminal nutrients provide GI structural support and help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
Reduces infectious complications associated with pneumonia, sepsis, IV line sepsis, and intra-abdominal abscess
Less expensive than PN

Question 613

List contraindications for enteral nutrition

Answer 613

Severe short bowel syndrome (<100-150 cm remaining small bowel w/o colon or 50-70 cm small bowel w/ colon)
Other severe malabsorptive conditions
Severe GI bleed
Distal high-output GI fistula
Paralytic ileus
Intractable vomiting and/or diarrhea that does not improve with medical management
Inoperable mechanical obstruction
When the GI tract cannot be accessed (when upper GI obstructions prevent feeding tube placement)

Question 614

What factors should be included when choosing a feeding tube?

Answer 614

Expected duration of therapy
Desired feeding location (stomach or small bowel)
Administration mode (continuous vs bolus)
Expertise of clinicians available for feeding tube placement

Question 615

What methods can be used for placement of long-term feeding tube?

Answer 615

Percutaneous endoscopy methods
Radiological methods using fluoroscopy, ultrasound, or CT
Open or laparoscopic

Question 616

List the various potential signs and symptoms of refeeding

Answer 616

Electrolyte abnormalities (hypophosphatemia, hypokalemia, hypomagnesemia, hypocalcemia, hyponatremia)
Cardiovascular conditions (arrhythmias, hypotension, heart failure, cardiac arrest)
Thiamin deficiency
Fluid retention
Hyperglycemia
Neurologic conditions (weakness, numbness, paresthesia, myalgia, vertigo)
Respiratory conditions (shortness of breath, pulmonary edema, respiratory failure)

Question 617

List risk factors for aspiration

Answer 617

Inability to protect the airway related to: reduced level of consciousness, neurologic deficit
Delayed gastric emptying related to: gastroparesis, medications (opioids), hyperglycemia, electrolyte abnormalities
Presence of naso- or oroenteric feeding tube
GERD
Supine position
Vomiting
Bolus enteral feeding
Mechanical ventilation
Age >70 years
Transport outside the ICU
Inadequate nurse-to-patient ratio
Poor oral care

Question 618

Define early EN initiation in the critically ill population

Answer 618

EN that is initiated with 24-48 hours of the initial insult (surgery, mechanical ventilation, neurological injury)

Question 619

Burn patients may benefit from early EN initiation, within __ to __ hours of injury

Answer 619

4-6 hours

Question 620

When are pump-assisted continuous drip infusions the preferred method for feeding patients?

Answer 620

Critical illness, mechanically vented using an oro-tracheal method, at risk for refeeding syndrome, poor glycemic control, fed via jejunostomy, demonstrated intolerance to intermittent gravity drip or bolus feed

Question 621

Should initiation of EN be delayed in the absence of bowel sounds or movements?

Answer 621

No; delayed EN will increase the risk of compromising the GI mucosal barrier and immune function

Question 622

How soon should EN be advanced to goal rate in stable noncritically ill patients?

Answer 622

Generally tolerate initially at the goal rate, should be advanced within 24-48 hours

Question 623

Standard initiation and advancement protocols for noncritically ill patients?

Answer 623

Start full strength at 50 ml/hr and advance by 15 ml q 4 hours to goal rate

Question 624

Standard initiation and advancement protocols for critically ill patients?

Answer 624

Start at 10-40 ml/hr and advance by 10-20 ml q 8 or 12 hours. However, many critically ill patients can tolerate rapid advancement of EN to goal rate within 24-48 hours, which results in smaller energy and protein deficits

Question 625

What are 2 EN volume-based protocols that have been shown to significantly improve nutrient delivery?

Answer 625

FEED ME (Feed Early Enteral Diet Adequately for Maximum Effect)
PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol)

Question 626

When should EN initiation be delayed in the critically ill population?

Answer 626

When considered hemodynamically unstable (those with MAP <50 mmHg or starting vasopressor medication/require increasing doses to maintain BP). Rare complication of ischemic bowel

Question 627

Factors that increase the risk for clogging a feeding tube?

Answer 627

Not flushing the tube with water, fiber-containing formulas, use of small-diameter tubes, use of silicone rather than polyurethane tubes, checking gastric residual volumes, and improper medication administration via the tube

Question 628

2009 ASPEN EN practice guidelines for water flushes in feeding tubes?

Answer 628

Recommend flushing feeding tubes with at least 30 ml of water every 4 hours during continuous feeding or before and after intermittent or bolus feeding in adult patients. Should also be flushed with 30 ml of water after gastric residual checks.

Question 629

What is the purpose of providing water flushes through feeding tubes?

Answer 629

Maintain tube patency, provided to meet hydration needs especially if patient is not receiving IV hydration of drinking fluids

Question 630

Tips regarding the form of a medication when given through enteral feeding tube

Answer 630

Use liquid or suspension forms when possible (liquid meds may contain sorbitol or be hyperosmotic, which can lead to diarrhea; if diarrhea occurs, an alternate medication regimen may be needed)
If tablet form must be used, consult with pharmacist to ensure it can be safely crushed and dispersed in water prior to administration.
Enteric-coated, sublingual, or sustained release tablets generally should NOT be crushed
Confirm appropriate medication delivery route with pharmacist. Medications that depend on gastric acid for breakdown or absorption may need to be substituted or given by alternate method if feeding tube is in duodenum or jejunum

Question 631

Tips regarding medication administration via the enteral feeding tube

Answer 631

Stop EN prior to the administration of meds; restart ASAP, only delay restarting EN when it is necessary to avoid altered drug bioavailability
Flush tube w/ at least 30 ml water before and after giving meds through tube
Give each med separately and flush tube w/ 5 ml warm water btwn meds
Do not mix meds or dosage forms, can affect drug stability and efficacy
If tube is smaller than 12 Fr, avoid using it to give crushed meds, if possible
Do not add meds to EN formula. This could increase incidence of tube occlusions, interfere with medication and nutrient bioavailability, affect GI function, and increase risk of microbial contamination

Question 632

Which EN delivery system is least likely to contribute to infection through bacterial contamination?

Answer 632

Closed system. Involves less manipulation and human/environmental contact with the EN formula and feeding sets

Question 633

How can contamination of an EN formula occur?

Answer 633

During preparation if additional modular components must be added to the formula
When feeding is transferred to the administration container
During assembly of the feeding system
During administration to the patient
Improper hand washing

Question 634

Name some factors that can compromise the accuracy of gastric residual volume (GRV) checks

Answer 634

Feeding tube type, diameter, and position
Viscosity of the GRVs
Technique, including size of the syringe and time and effort spent
Position of the patient

Question 635

What other methods, aside from checking GRVs, should be used to assess GI function

Answer 635

Passage of flatus
Stool frequency and consistency
Physical examination to assess bowel sounds and abdominal girth
Abdominal radiographs

Question 636

Describe conditions in which patients are at a high risk for dehydration

Answer 636

Those with increased fluid losses, high GI volume output
Diarrhea, colostomies, ileostomies, fistulas
High fever, burns, extensive wounds
Highly osmolar enteral nutrition (osmotic diuresis related to an increased renal solute load)

Question 637

Causes of hyperglycemia in hospitalized patients that aren’t related to diabetes

Answer 637

Multifactorial, including increased release of counterregulatory hormones that stimulate gluconeogenesis , proinflammatory cytokines that result in insulin resistance, provision of steroid and adrenergic medications, and excess dextrose administration via IV fluid solutions and medications.

Question 638

Target blood sugar range per SCCM/ASPEN guidelines for hospitalized patients?

Answer 638

140-180 mg/dL

Question 639

What are potential causes of slowed/delayed gastric emptying? (~13 total)

Answer 639

• diabetic gastropathy
• hypotension
• sepsis
• stress
• anesthesia and surgery
• infiltrative gastric neoplasms
• various autoimmune diseases
• surgical vagotomy
• pancreaticoduodenectomy
• opiate analgesic meds (morphine sulfate, codeine, fentanyl)
• anticholinergics (chlordiazepoxide hydrochloride and clidinium bromide)
• excessively rapid infusion of formula
• infusion of very cold solution or one containing a large amount of fat or fiber

Question 640

What are appropriate interventions for delayed gastric emptying?

Answer 640

-reducing/discontinuing all narcotic meds
-switching to a low-fiber, low-fat, and/or isotonic formula
-administering the TF formula at room temp
-temporarily reducing the rate of infusion by 20 - 25 mL/hr
-changing the infusion method from bolus to continuous
AND/OR
-administering prokinetic agent (metoclopramide or erythromycin).

Question 641

What if the patient has N/V as the TF rate is advancing to goal?

Answer 641

The rate or volume should be reduced to the greatest tolerated amount, with an attempt to increase the rate again after symptoms abate.

If this fails, small bowel access should be considered

Question 642

(T/F) Elevated GRVs correlate with TF intolerance.

Answer 642

FALSE. They DO NOT

Question 643

**What does SCCM/ASPEN recommend for GRVs in critically ill patients?

Answer 643

**SCCM/ASPEN does not recommend routine checks of GRVs in critically ill patients.

Question 644

What should the clinician monitor, and potentially recommend for patients with nausea, but low GRVs?

Answer 644

Patient may benefit from antiemetic medications. Clinicians should monitor stool frequency.

Question 645

What are potential causes of abdominal distention?

Answer 645

• GI ileus
• Obstruction
• Obstipation
• Ascites
• Diarrheal illness
• Excessively rapid formula administration or infusion of very cold formula
• Use of fiber-containing formulas

Question 646

How is abdominal distention diagnosed?

Answer 646

By visual inspection and palpation, and patient reports.

Clinical evaluation remains the most practical means of assessment.

Question 647

How is distention defined?

Answer 647

No objective definition, suggestion is “an increase in abdominal girth of more than 8 to 10 cm”

Question 648

What is the appropriate screening method for ileus or obstruction?

Answer 648

Plain radiology; sometimes cross-sectional imaging (computed tomography) may be needed to confirm the dx.

Question 649

If a patient has a feeding tube and distention is suspected and/or the location of the feeding tube, what method can be used?

Answer 649

A small amount of contrast material injected through the feeding tube, and the intestinal anatomy and motility is observed on a follow-up, single x-ray or under fluoroscopy.

If motility is poor and the bowel is markedly dilated, or the patient’s discomfort is too severe, the feedings may need to be discontinued.

Question 650

Define maldigestion.

Answer 650

refers to impaired breakdown of nutrients into absorbable forms (ie: lactose intolerance); may result in significant malabsorption

Question 651

What are the clinical manifestations of maldigestion?

Answer 651

• Bloating
• Abdominal distention
• Diarrhea

Question 652

Define malabsorption

Answer 652

Defective mucosal uptake and transport of nutrients (fat, carbs, protein, vitamins, electrolytes, minerals, or water) from the small intestine.

Question 653

What are the clinical manifestations of malabsorption?

Answer 653

• Unexplained weight loss
• Steatorrhea
• Diarrhea
• Signs of vitamin, mineral, or essential macronutrient deficiency (anemia, tetany, bone pain, bleeding, neuropathy, glossitis)

Question 654

What are the methods used to screen for malabsorption?

Answer 654

(Listed in order of complexity)

• Gross and microscopic examination of the stool
• Qualitative determination of fat and protein content of a random stool collection
• Measurement of [serum carotene]
• Measurement of [serum citrulline]
• Measurement of d-xylose absorption
• Radiologic exam of intestinal transit time and motility

Question 655

What methods can be used to diagnose malabsorption?

Answer 655

• Intake/output balance (stool collections for quantitative fecal fat assessment)
• Tests for maldigestion/malabsorption for specific nutrients, ie: lactose tolerance test; Schilling test to screen for abnormal absorption of vitamin B12, etc.
• Endoscopic small bowel biopsy, which is helpful in dx mucosal disorders (Celiac, tropical sprue, Whipple disease)

Question 656

What are some diseases that cause maldigestion/malabsorption?

Answer 656

• Gluten-sensitive enteropathy
• Crohn’s disease
• Diverticular disease
• Radiation enteritis
• Enteric fistulas
• HIV
• Pancreatic insufficiency
• Short-gut syndrome
• SIBO (small intestinal bacterial overgrowth)
• ETC

Question 657

(T/F) It is recommended to use predigested enteral formula when malabsorption is suspected.

Answer 657

INBETWEEN. It is common practice to use predigested enteral formulas; but only weak data supports their use to prevent intolerance.

Selected patients with severe malabsorption that is unresponsive to medical therapy or supplementation may require PN.

Question 658

How is diarrhea defined?

Answer 658

“any abnormal volume or consistency of stool”

Greater than 500 mL stool output every 24 hours or more than 3 stools per day for at least 2 consecutive days.

Question 659

How much sorbitol can cause diarrhea?

Answer 659

10 - 20 grams

Question 660

**How should medications that contain sorbitol be administered?

Answer 660

Any drug in a liquid vehicle given via a small bowel feeding tube should be diluted to avoid a hypertonic-induced, dumping-like syndrome.

**Most drugs and electrolytes (ie: potassium), should be mixed with a minimum of 30 to 60 mL water per 10 mEq dose to avoid direct irritation of the gut.

Question 661

If clinically significant diarrhea develops during EN, clinicians should consider what options? (5)

Answer 661

• Medical assessment to rule out infectious or inflammatory causes, fecal impaction, diarrheagenic meds, etc.
• Use of antidiarrheal agent

Question 662

(T/F) SIBO is being increasingly seen in patients s/p Roux-en-Y gastric bypass surgery.

Answer 662

TRUE

Question 663

(T/F) When EN fed patients develop diarrhea, abdominal upset or fever, the contamination of enteral formula and the enteral delivery system should be considered as a potential cause of the problem.

Answer 663

TRUE

Question 664

How often should feeding bags be changed?

Answer 664

Every 24 hours.

Feeding bags do not need to be rinsed with water before additional formula is added, but formula should not be added until the previous formula has infused.

Question 665

How often should ‘closed’ EN delivery system, such as spike sets, be change?

Answer 665

Every 24 hours to reduce the incidence of diarrhea

Question 666

How should disconnections within the enteral delivery system be handled?

Answer 666

They should be minimized. When they are necessary, the distal end of the delivery system should be covered with a clean cap and long periods of formula stagnation should be avoided.

Question 667

Define constipation.

Answer 667

Difficult to define given normal defecation patterns range from 4 stools/day to 1 stool every 4 to 5 days.

The best clinical definition is the accumulation of excess waste in the colon, often up to the transverse colon or even the cecum

Question 668

What is the best method for diagnosis of constipation?

Answer 668

Plan abdominal x-ray, and can differentiate from SBO or ileus

Question 669

What are the two main causes of constipation?

Answer 669

• Dehydration

- Inadequate or excessive dietary fiber intake

Question 670

If a patient has constipation, but excessive fluid is a concerned, what you recommend?

Answer 670

Addition of a stool softener: docusate sodium or docusate calcium; Addition of a laxative or cleansing enema may be needed.

Note: Chronic use of stimulants (ie: senna) often results in tachyphylaxis (rapidly diminishing responsive to successive doses of a drug) and is not indicated.

Question 671

If fiber is added to the enteral regimen, what equation should you use to calculate fluid needs.

Answer 671

1 mL/kcal/day; may help prevent solidification of waste in the colon and constipation.

Question 672

Define impaction.

Answer 672

A firm collection of stool in the distant colon (sigmoid colon or rectum). Liquid stool will seep around an impaction, occasionally at high volume.

Question 673

When should impaction be considered in patients? And which patients?

Answer 673

When stool volumes have been small and then become liquid. Specifically, in older adults and patients who are bedbound.

Question 674

What is used to treat impaction?

Answer 674

Enemas, cartharics (sorbitol, lactulose), and even endoscopy in severe cases.

Question 675

What is NOBN? Who is at higher risk?

Answer 675

Nonocclusive bowel necrosis

Neonates, critically-ill and immune-suppressed patients, and patients with a compromised gastric acid microbial barrier

Question 676

What are underlying factors for NOBN?

Answer 676

• Use of jejunal feedings
• Hyperosmolar formulas
• Feeding in the presence of hypotension and disordered peristalsis

Question 677

What are the clinical manifestations of NOBN? What is the treatment?

Answer 677

Abdominal distention, N/V

Precautionary measures are used, most importantly, delaying EN until the patient is fluid-resuscitated

Question 678

How can aspiration be detected in patients?

Answer 678

By detecting either pepsin (major enzyme found in gastric fluid) OR yellow microscopic beads (added to the TF)

Question 679

What is the most reliable method for detecting pulmonary aspiration of TF formula?

Answer 679

There is none. Radiographic findings are generally non-specific and insensitive.

Question 680

(T/F) Glucose assay strips are available for routine clinical use to detect high glucose level in tracheal aspirates, to possibly detect that aspirates contain TF formula

Answer 680

FALSE; These assays are not available for routine use

Question 681

(T/F) Elevated GRVs can predict vomiting or reflux.

Answer 681

TRUE; clinicians have used GRV to determine the risk for aspiration as well

Question 682

(T/F) Other methods for detecting gastric emptying delays during EN include: scintigraphy, paracetamol absorption test, carbon-isotope breath test, refractometry, ultrasound, gastric impedance.

Answer 682

FALSE. These are all experimental or of unproven value; also time-consuming, difficult to perform at bedside and require standardization and validation in critically ill patients

Question 683

What angle should the HOB be positioned at to decrease reflux and aspiration PNA?

Answer 683

30 - 45 degrees

If that is contraindicated, use the reverse Trendelenburg position

Question 684

**What are the SCCM/ASPEN guidelines for GRVs in ICU patients?

Answer 684

**GRVs should not be used as part of the routine care to monitor ICU patients receiving EN.

**If ICUs still use GRVs, it is recommended that clinicians avoid holding EN for GRVs less than 500 mL, in the absence of other signs of feeding intolerance (quality of evidence: low).

Question 685

*What are the guidelines for tube-fed patients for preventing TF intolerance?

Answer 685

• Assessed for signs of tube-feed intolerance (distention, fullness feeling, discomfort, N/V) Q 4 hours
• HOB elevation 30 - 45 degrees, or position in chair or reverse Trendelenburg position
• Good oral care BID (with chlorhexidine in critically ill patients)
• Continuous tube feeding schedules
• Use of minimal sedation techniques
• Appropriate and timely oropharyngeal suctioning (ie: prior to lowering the bed, deflating the cuff of endotracheal tubes or extubation)
• Tube placement should be checked by noting any change in the visible tube length or marking at stoma Q 4 hours
• Unless the patient is vomiting, GRVs up to 250 mL should be re-instilled to replace fluid, electrolytes and feeding formula.
• Prokinetic agents and small bowel feedings should be considered for patients determined to be at high aspiration risk

Question 686

**What are the SCCM/ASPEN guidelines for EN in patients at risk for refeeding syndrome?

Answer 686

**Should provide only 25% of the energy goal on Day 1, with attention to the energy contribution from IV fluids, and then cautiously advanced toward the energy goal over the next 3 to 5 days, as dictated by clinical status and/or stable electrolyte levels.

Question 687

Define dehydration.

Answer 687

An excessive fluid volume deficit, which may be accompanied by sodium imbalance.

Question 688

What causes dehydration? What is it associated with?

Answer 688

Caused by insufficient fluid intake, and/or excessive fluid losses, such as from fever, D, V, significant blood volume loss, chronic illness (diabetes, kidney disease), overuse of diuretics, drainage tube or paracentesis losses, wound seepage, or high nasogastric, fistula or ostomy outputs.

Dehydration is associated with an increased risk of falls, pressure ulcers, constipation, UTIs, respiratory infections, and medication toxicities.

Question 689

What are early signs of dehydration?

Answer 689

• Dry mouth and eyes
• Thirst
• Lightheadedness
• Headache
• Fatigue
• Loss of appetite
• Flushed skin
• Heat intolerance
• Dark urine with a strong odor

Tongue dryness can be a simple, quick, reliable, cost-effective way to identify dehydration in older adults

Question 690

What are signs of progressive dehydration?

Answer 690

• Dysphagia
• Clumsiness
• Poor skin turgor (sternum: more than 2 seconds)
• Sunken eyes with dim vision
• Painful urination
• Muscle cramps
• Delirium

Question 691

What laboratory values are seen in dehydrated patients?

Answer 691

Elevation in BUN, plasma osmolality, and hematocrit, whereas [sodium] can be elevated, low, or normal depending on the etiology of dehydration.

Usually the BUN rises out of proportion to the usual BUN-to-creatinine ratio of 20:1.

Question 692

What is the minimum urine output required to remove waste?

Answer 692

30 mL/hr or about 700 mL/day

*An output of at least 1 mL/kg/h is useful as a guidelines for adequate urine output

Question 693

When should fluid intakes be increased?

Answer 693

if a patient develops a fever, emesis, diarrhea, high fistula and ostomy outputs or hyperglycemia

Question 694

For patients with fever, how much should their fluid intakes be increased?

Answer 694

Increase by 12% per degree Celsius above 37.8.

Question 695

**What are EN practice recommendations from ASPEN, include what statements regarding enteral formulation selection? (3)

Answer 695

• *1. The accuracy of adult enteral formula labeling and product claims is dependent on formula vendors
  
  2. Nutrition support clinicians and consumers are responsible for determining the accuracy of information about adult enteral formulas.
  3. Interpret enteral formulations content/labeling and health claims with caution until such time as more specific regulations are in place.

EN formulas are not FDA-approved, so their claims are not regulated.

Question 696

Explain carbohydrate composition for EN formulations, in general

Answer 696

40 - 70% of their energy as carbs; primary macronutrient
Polymeric formulas use mostly corn syrup solids as carb source

Hydrolyzed formulas use maltodextrin or hydrolyzed cornstarch as the carb. source

Most formulas do not contain lactose.

Question 697

Explain fiber composition for EN formulations, in general

Answer 697

Guar gum and soy fiber are the common fiber sources

Soluble fiber may help control diarrhea due to its ability to increase sodium and water absorption via its fermentation byproducts, SCFAs

Insoluble fiber may help to decrease transit time by increasing fecal weight

Question 698

**What are the ASPEN/SCCM recommendations related to use of fiber in EN formulations?

Answer 698

**They suggest that clinicians consider fiber-containing formulas if patients have persistent diarrhea.

Also, both insoluble and insoluble fiber be avoided if the patients are at a high risk for bowel ischemia and have severe dysmotility.

Question 699

Why may the prebiotic fibers (in fiber-containing EN formulas) provide benefits to some patients?

Answer 699

Some EN formulas contain FOS (fructooligosaccharides), aka prebiotics that help promote growth of beneficial bacteria, in the distal bowel and are fermented to produce SCFAs

Question 700

Explain fat composition for EN formulations, in general

Answer 700

Concentrated energy source, and provides essential FAs

Usually contain a mixture of LCTs and MCTs (MCTs do not provide EFAs and are also not stored, LCTs are also added)

Corn and soybean oil are the most common sources used; safflower, canola and fish oils are also used

Question 701

What are structured lipids?

Answer 701

“are a chemical re-esterification of LCTs and MCTs on the same glycerol backbone, offering advantages of MCTs, while including enough LCTs to meet EFA needs”

Some EN formulas contain these lipids

Question 702

Define hydolyzed protein

Answer 702

small peptides (more than 3 AA residues)

Question 703

Define Semi-elemental or Elemental formulas

Answer 703

aka dipeptides, tri-peptides, and free AA

Any peptide greater than 3 AAs require further hydrolyzation prior to absorption

Question 704

Most enteral formulations provide adequate amounts of vitamins and minerals to meet DRIs when provided in what volumes/day?

Answer 704

1000 - 1500 mL/day

Supplementation should be considered for patients when the enteral formula does not meet their v/m needs

Question 705

(T/F) Standard enteral formulas contain modest amounts of electrolytes, typically enough to meet daily needs in most patients when the formula is provided in adequate amounts to meet DRIs.

Answer 705

TRUE

Question 706

How much (% range) do enteral formulas contain by volume?

Answer 706

70 - 85%

Most patients receiving EN require an additional source of water to meet their fluid needs (IVF, additional water flushes)

Question 707

Define osmolality, when referring to EN formula.

Answer 707

“is the concentration of free particles, molecules, or ions in a given solution, and is expresed as milliosmoles per kg of water (mOsm/kg).”

Osmolality of EN formula ranges from: 280 - 875 mOsm/kg.

As the content of free particles, ions or molecules increases in the product, so does the osmolality.

For example, formulas containing sucrose have a higher osmolality than those with cornstarch or maltodextrin.

Formulas with single AAs or high amounts of di- or tri-peptides, also have higher osmolality than those with intact proteins.

Question 708

Define hypertonic enteral formulations

Answer 708

Osmolality greater than 320 mOsm/kg.

Are frequently blamed for formula intolerance, like diarrhea, etc. Which can result when these formulas (especially ones with sucrose) are delivered directly to the SI, causing dumping syndrome. This problem is unlikely to occur when peptide or single AAs are provided in the same manner

*Other than simple sugar-related hyperosmolality, the osmolality of an enteral formula has little to do with formula tolerance.

Question 709

What is EN formula tolerance or diarrhea, most often related to? (4)

Answer 709

• Severity of illness
• Co-morbid conditions
• Enteric pathogens
• Concomitant use of meds administered through the enteral access device

Question 710

Describe diabetes-specific EN formulas.

Answer 710

Lower in carbs (33 - 40%), higher in monounsaturated fat and total fat (42 - 54%) and provide more fiber (14 - 16 g/L) than standard polymeric formulas.

Rationale: Fiber will slow gastric emptying, leading to better glycemic control

Question 711

What does the ADA (American Diabetes Association) recommend for DM management?

Answer 711

“Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals”

“Ideal quantity of carbs intakes as well as insulin therapy should be individualized for each patients”

Note fiber is not usually appropriate to use in critically-ill patients

Question 712

**What do North American nutrition support guidelines say for diabetic patients in the ICU?

Answer 712

**Does not recommend the use of diabetes-specific formulas based on the evidence available.

Question 713

(T/F) Switching to a diabetes-specific EN formula is the first step in management of hyperglycemia?

Answer 713

FALSE: Blood glucose control should be optimized by appropriate energy provision and insulin therapy, usually insulin gtt in the ICU setting.

Providing SSI “as needed” is not effective in controlling BG within the recommended range of 140 - 180 mg/dL

Question 714

**What does ESPEN/ASPEN recommend for elemental EN formula use with patients with GI issues?

Answer 714

**ESPEN does not recommend the routine use of elemental formulas with Crohn’s disease, ulcerative colitis, or short-bowel syndrome.

**ASPEN also recommends that routine elemental and disease-specific EN formulas be avoided in critically ill patients because no clear benefit to patient outcomes has been shown in the literature.

Question 715

What does the research show for hepatic encephalopathy EN formulas?

Answer 715

No evidence that the use of high-BCAAs formulations alter patient outcomes compared to standard formulas.

Hepatic encephalopathy is a complication of liver failure and elevated blood ammonia, so the rationale is a formula with lower protein, increased amounts of BCAAs, and decreased amounts of AAAs were developed for this patient population.

BCAA supplementation has been associated with an increased risk of nausea and vomiting, as well

Question 716

Define immune-modulating formulations (IMFs).

Answer 716

EN formulas that contain arginine, glutamine, omega-3 FAs, nucleotides, and antioxidants

These specific nutrients are thought to have potential to modulate the metabolic response to surgery/stress

Question 717

Explain how/why the effects of arginine differs from surgical vs. non-surgical patients.

Answer 717

It relates to metabolism

Surgical: in patients undergoing surgery for head/neck cancers, arginine-containing formulas were associated with reduction in fistula and LOS

Question 718

**What are SCCM/ASPEN guidelines for IMFs in critically ill patients?

Answer 718

• *1. Do not recommend the routine use of IMFs with severe sepsis.
  2. Recommend IMF use be reserved for the postoperative patients in the surgical ICU.

Question 719

Define respiratory quotient (RQ).

Answer 719

“a value that describes CO2 production in relation to oxygen consumption, varies for carbs (1.0), protein (0.8), and lipid (0.7)”

Research has showed that total energy provision or overfeeding was more important than composition of formula in respiratory status of vented patients.

Question 720

Explain EN formulas specified for respiratory disease.

Answer 720

Energy dense, in order to accommodate for fluid restrictions and/or elevated energy requirements and altered respiratory function

Formulations are low in carb (27%), high in lipid (55%), with moderate amounts of protein

Ambulatory patients: formulas will have corn and safflower oils

ARDS/ALI patients: will contain fish oil and borage oil

*High doses of omega-6 FAs are not recommended because of their potential to exacerbate the inflammatory state already present.

Question 721

What does the research show regarding critically ill patients with ARDS/ALI, receiving specialized EN formulas?

Answer 721

Inconsistent

Question 722

**What does SCCM/ASPEN recommend for specialized formulas for ARDS/ALI?

Answer 722

**Does not recommend for ARDS/ALI

Also, does not recommend the use of high-fat, low-carb formulas containing high levels of omega-6 FAs

Question 723

**What does SCCM/ASPEN recommend for EN formulas for patients (in ICU) with AKI?

Answer 723

**They recommend the use of standard, high-protein EN formulas for AKI.

Patients with hyperkalemia or hyperphosphatemia may require a renal-specific formula.

Question 724

**What does SCCM/ASPEN recommend for EN formulas for patients with acute respiratory failure?

Answer 724

**They recommend the use of concentrated formulas, because of the presence of concomitant fluid overload, pulmonary edema, and renal failure. These formulas may also be used in other disease states and conditions, such as liver and heart failure, that result in fluid overload, hypervolemic hyponatremia, decreased urine output, early satiety, and elevated nutrition needs.

Question 725

Define beta-hydroxy beta-methylbutyrate (HMB)? What does it do metabolically?

Answer 725

a metabolite of BCAA leucine; a dietary supplement that results in positive patient outcomes (THINK ENSURE).

HMB promotes anabolism by increasing protein synthesis and inhibiting the ubiquitin-proteasome pathway controlling protein degradation, so conserving and even promoting accretion of LBM.

It helps preserve LBM in patients w/ sarcopenia, cancer cachexia, and AIDS

Research is limiting to support routine use and effectiveness of these supplements in patients with wasting syndrome

Question 726

Pharmacological dosing of what nutrients is linked to improved wound healing? (6)

Answer 726

• Glutamine
• Arginine
• Omega-3 FAs
• Zinc
• Selenium
• Vitamin A
• Vitamin C

Question 727

**What are the SCCM/ASPEN recommendations for critically ill obese patients?

Answer 727

**They recommend these patients should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores

The energy goal should not exceed 65 - 70% of energy requirements as calculated.

Question 728

**What are the equations for estimating energy needs in obese ICU patients, when IC is not available?

Answer 728

** For BMI 30 - 50: Use 11-14 kcal/kg ACTUAL weight

For BMI greater than 50: Use 22 - 25 kcal/kg IBW

Question 729

**What is the protein recommendation for critically ill obese patients?

Answer 729

More than 2.0 g/kg/day protein is adequate to maintain nitrogen balance with hypocaloric feedings, preserve LBM, and allow for adequate wound healing

Question 730

What is NPC:N?

Answer 730

Nonprotein calorie-to-nitrogen ratio

Most EN formulations have a high NPC:N; therefore, protein modulars are usually needed to meet the protein needs of the obese patient

Question 731

Define modular products?

Answer 731

Typically, a single nutrient product and are available for use in addition to the selected enteral formulations.; protein powders are the most popular

Question 732

Define PDCAAS.

Answer 732

Protein digestibility corrected amino acid score; it assesses the bioavailability of essential AAs as a protein module; used by manufacturers of modulars for product competition.

Question 733

Why do you need to be cautious of liquid modulars?

Answer 733

They are often hyperosmolar and caution should be taken before administering into the feeding tube

Powder and liquid modulars can be mixed in with beverages and oral supplements. If patient is NPO w/ TF, modular should be flushed like a med down feeding tube, never mixed with EN formula

Question 734

What are the considerations for healthcare facilities when developing an enteral formulary? (5)

Answer 734

1. Patient acuity
2. Digestive and absorptive capacity, organ dysfunction, and metabolic requirements of most patients
3. Formulation components that may be contraindicated
4. Need for fluid restriction
5. Need for added formulation components

Enteral formulary contracts should ALWAYS include a clause that allows the facility to purchase a noncompeting product if it better meets the nutrition needs of patients.

Always complete a cost-benefit analysis when developing a formulary to choose appropriate products and limit expenditure

Question 735

What is the hang time for ‘open system’ EN?

Answer 735

8 to 12 hours

Any non-sterile formula, such as powder formula, that needs to be reconstituted with sterile water, should not hang FOR MORE THAN 4 HOURS. It can be mixed ahead and refrigerated for no more than 24 hours after preparation

Question 736

What is the hang time for ‘ready-to-hang/closed system’ EN?

Answer 736

24 to 48 hours, depending on manufacturer instructions

Biggest drawback is high amount of waste, if switching formulas etc, and misconnection errors, now being solved by the ENfit connector

Question 737

EN practice recommendations from ASPEN regarding enteral formula selection

Answer 737

The veracity (accuracy, credibility) of adult enteral formula labeling and product claims is dependent on vendors
Nutrition support clinicians and consumers are responsible for determining the veracity of information about adult enteral formulations
Interpret enteral formulation content/labeling and health claims with caution until such time as more specific regulations are in place

Question 738

Define standard/polymeric enteral nutrition formula?

Answer 738

Formula containing macronutrients as nonhydrolyzed protein, fat, carbs

Question 739

Define elemental and semi-elemental enteral nutrition formulas?

Answer 739

Contains partially or completely hydrolyzed nutrients (protein) and altered fats to maximize absorption

Question 740

Define blenderized enteral nutrition formula?

Answer 740

Formulated with a mixture of blenderized whole foods, with or without the addition of standard formula; best suited for patients with a healed feeding site and for those who adhere to safe food practices and tube maintenance

Question 741

Define disease-specific enteral nutrition formulas?

Answer 741

Targeted for organ dysfunction or specific metabolic conditions

Question 742

Define a modular

Answer 742

Used for supplementation to create a formula or enhance nutrient content of a formula or diet

Question 743

Name carbohydrate sources of polymeric enteral formulas?

Answer 743

Main: corn syrup solids
Other: hydrolyzed corn starch, maltodextrin, sucrose, fructose, sugar alcohols

Question 744

Name carbohydrate sources of elemental formulas?

Answer 744

Cornstarch, hydrolyzed cornstarch, maltodextrin, fructose

Question 745

Name fat sources of polymeric formulas?

Answer 745

Borage oil, canola oil, corn oil, fish oil, high-oleic sunflower oil, MCT, menhaden oil, mono- and diglycerides, palm kernel oil, safflower oil, soybean oil, soy lecithin

Question 746

Name fat sources in elemental formulas?

Answer 746

Fatty acid esters, fish oil, MCT, safflower oil, sardine oil, soybean oil, soy lecithin, structured lipids

Question 747

Why might palm kernel and coconut oil be added to an enteral formula?

Answer 747

As a source of MCTs

Question 748

Describe some advantages of using MCTs in enteral formulations? Disadvantage?

Answer 748

Absorbed directly into the portal circulation and do not require chylomicron formation for absorption.
Do not require pancreatic enzymes or bile salts for digestion and absorption.
Cleared from the blood stream rapidly and cross the mitochondrial membrane without the need for carnitine, where they are oxidized to CO2 and water and therefore are not stored.
Disadvantage: MCTs do not provide EFAs, so most enteral formulations contain a mixture of LCTs and MCTs

Question 749

What are structured lipids?

Answer 749

Chemical re-esterification of LCTs and MCTs on the same glycerol backbone. They offer advantages of MCTs while including enough LCTs to meet EFA needs

Question 750

Describe the health benefits of omega-3 fatty acids?

Answer 750

Omega-3 fatty acid end products are metabolized to prostaglandins of the 3 series and leukotrienes of the 5 series, which are associated with anti-inflammatory effects, slowing of platelet aggregation, immune enhancement, and antiarrhythmic properties

Question 751

What are the most commonly used sources of intact protein in enteral formulations?

Answer 751

Casein and soy protein

Question 752

Elemental or semi-elemental enteral formulas contain protein in what forms?

Answer 752

Hydrolyzed protein, small peptides (more than 3 amino acid residues), dipeptides and tripeptides, and free amino acids

Question 753

What populations are elemental and semi-elemental enteral formulas intended for?

Answer 753

GI dysfunction such as short bowel syndrome, malabsorption, or pancreatic exocrine insufficiency

Question 754

Name common fiber sources in enteral formulas?

Answer 754

Guar gum and soy fiber

Question 755

What is the purpose to soluble fiber in an enteral formula?

Answer 755

It is fermented by the gut microbiota in the distal intestine to produce short-chain fatty acids (SCFAs)- which are a source of energy for colonocytes and help increase intestinal mucosal growth and promote water and sodium absorption. May help control diarrhea due to its ability to increase sodium and water absorption. Some formulas supplemented with soluble fiber have been shown to reduce incidence of diarrhea

Question 756

SCCM guidelines on fiber-containing enteral formulas?

Answer 756

Suggest that clinicians consider their use if patients have persistent diarrhea, and suggest both insoluble and soluble fiber be avoided if patients are at a high risk for bowel ischemia and have severe dysmotility

Question 757

Describe the relationship of fiber-containing formulas with the frequency of bowel movements according to a systematic review

Answer 757

Fiber-containing formulas reduced bowel frequency when baseline bowel frequency was high and increased bowel frequency when baseline bowel frequency was low.

Question 758

Benefits of fiber in an enteral formula?

Answer 758

May speed up transit time, increase fecal bulk, reduce constipation, and improve gut barrier function through the stimulation of colonic bacteria

Question 759

True or false: Research suggests nitrogen absorption is greater with enteral formulations containing only free amino acids

Answer 759

False. Suggests absorption may be greater with peptide-based formulations

Question 760

Most enteral formulations provide adequate amounts of vitamins and minerals to meet DRIs when provided in volumes of ___ to ___ mL/day

Answer 760

1000-1500 mL/day

Question 761

Define the osmolality of an enteral formula and typical ranges

Answer 761

The concentration of free particles, molecules, or ions in a given solution, expressed as milliosmoles per kilogram of water (mOsm/kg).
Ranges from 280-875 mOsm/kg

Question 762

Does the osmolality increase or decrease as the content of free particles, ions, or molecules increases?

Answer 762

Increases

Question 763

Describe some contents of formulas that would have a higher osmolality than others

Answer 763

Formulas with sucrose rather than cornstarch or maltodextrin have higher osmolality
Formulas with single amino acids or high amounts of di- and tripeptides rather than intact protein have higher osmolality

Question 764

When is a formula considered hypertonic?

Answer 764

When the osmolality is >320 mOsm/kg

Question 765

Under what circumstance would it be reasonable to relate a patient’s diarrhea to the osmolality of the enteral formula used?

Answer 765

When hyperosmolar formulas containing sucrose are delivered directly into the small intestine, dumping syndrome can occur. But this problem is unlikely to occur when peptide or single amino acids are provided in a similar manner

Question 766

Describe considerations when evaluating research or specialized enteral formulas

Answer 766

In vitro (animal) versus in vivo (human) study
Quality of study design (prospective randomized controlled trial, retrospective review, case reports)
Similarity of patient population studied to patients being cared for (demographic factors, clinical status, clinical environment, etc)
Generalizability of results

Question 767

Describe the general macronutrient distribution of diabetes-specific formulas and the reasoning?

Answer 767

Lower in carbs (33-40% of total energy)
Higher in monounsaturated fat and total fat (42-54% of total energy)
Provide more fiber (14-16 gm/L) than standard polymeric formulas
Rationale is that this mixture of low carb, high fat and fiber will slow gastric emptying and lead to better glycemia control

Question 768

ADA macronutrient distribution recommendation for patients with diabetes?

Answer 768

There is not an ideal percentage of calories from carbs, protein, and fat for all patients with diabetes. Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. The ideal quantity of carb intake as well as insulin therapy should be individualized for each patient.

Question 769

What is the best approach to enteral nutrition management in a post-op patient with T2DM?
Scenario: 56 y/o M PMH of T2DM and HTN admit to STICU s/p aortic valve replacement. Intubated and sedated post-op day 1 getting IV fluids @ 100 ml/hr using 5% dextrose with half-normal saline. 5’10” and 80 kg (5kg less than 2 months prior). All lab values insignificant except BG which were consistently >180 mg/dL. Treated with subcutaneous insulin q 4 hr following standard glucose monitoring schedule. Energy requirements estimated 2000 kcal/day, protein 96-120 gm/day (1.2-1.5 g/kg/day). EN started ICU day 1 using diabetes-specific formula at 30 ml/hr and insulin management unchanged. After initiation of EN, BG levels continued to be higher than 180 mg/dL

Answer 769

Diabetes- specific formula is not necessary in ICU patients with diabetes and hyperglycemia. Pt was experiencing hyperglycemia prior to initiation of EN due to T2DM, postsurgical stress, and IV fluids (were providing 400kcal from dextrose). Intervention: change to standard 1.0 kcal/ml polymeric formula, decrease IV fluids and change to 1/2 NS, start continuous IV insulin infusion

Question 770

Name some prebiotics

Answer 770

Fructooligosaccharides (FOS) and inulin

Question 771

ASPEN recommendation regarding routine use of elemental formulas in critical illness?

Answer 771

Recommend that routine use of elemental and disease-specific formulas be avoided in critically ill patients because no clear benefit has been shown in the literature.

Question 772

Why have the branched chain amino acids (BCAAs) leucine, valine, and isoleucine been promoted for use in hepatic encephalopathy?

Answer 772

Because they clear ammonia in the skeletal muscles, decreasing cerebral ammonia levels and reducing the uptake of aromatic amino acids (AAAs) across the blood-brain barrier

Question 773

Is protein restriction recommended in liver failure?

Answer 773

No; leads to a further decline in nutrition status and lean body mass and may result in higher ammonia levels

Question 774

Define immune-modulating formulations (IMFs)

Answer 774

Enteral formulas that contain arginine, glutamine, omega-3 polyunsaturated fatty acids, nucleotides, and antioxidants. These specific nutrients are thought to have the potential to modulate the metabolic response to surgery or stress

Question 775

SCCM/ASPEN guidelines regarding the use of IMFs in critical illness?

Answer 775

Guidelines do not recommend the routine use to IMFs with severe sepsis; IMF use should be reserved for the post-op patient in the surgical ICU

Question 776

What is the respiratory quotient (RQ) for each macronutrient?

Answer 776

RQ is a value that describes CO2 production in relation to oxygen consumption
Carb: 1.0
Protein: 0.8
Lipid: 0.7

Question 777

Describe the role of HMB (beta-hydroxy beta-methylbutyrate) in wasting conditions?

Answer 777

HMB is a metabolite of leucine. Promotes anabolism by increasing protein synthesis and inhibiting the ubiquitin-proteasome pathway controlling protein degradation, thereby conserving and even promoting accretion of LBM. Helps preserve LBM in patients with sarcopenia, cancer cachexia, and AIDS

Question 778

Name nutrients beyond energy and protein that are linked with improving patient outcomes in regard to wounds

Answer 778

Glutamine, arginine, omega-3 fatty acids, zinc, selenium, and vitamins A, C, and E

Question 779

SCCM/ASPEN guidelines regarding nutrient provision in critically ill obese population?

Answer 779

The critically ill obese patient should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores

Question 780

How might weight loss positively influence outcomes in the critically ill obese patient?

Answer 780

Weight loss may increase insulin sensitivity, facilitate nursing care, and reduce the risk of comorbidities

Question 781

Enteral formulas that provide 1 kcal/ml have a higher or lower NPC:N (nonprotein calorie-to-nitrogen) ratio?

Answer 781

Lower

Question 782

What makes 1 kcal/ml enteral formulas a good choice for critically ill obese patients?

Answer 782

Lower NPC:N ration, less need for protein modular, additional fluid

Question 783

What factors should be considered when developing an enteral formulary?

Answer 783

Patient acuity
Digestive and absorptive capacity, organ dysfunction, and metabolic requirements of most patients
Formulation components that may be contraindicated
Need for fluid restriction
Need for added formulation components

Question 784

How often should administration sets for open system enteral feedings be changed?

Answer 784

At least every 24 hours

Question 785

Recommended hang time for powdered, reconstituted formula and EN formula with additives?

Answer 785

4 hours

Question 786

Recommended hang time for closed-system EN formulas?

Answer 786

24-48 hours

Question 787

Recommended hang time for sterile, decanted formula?

Answer 787

8 hours

Question 788

What is the maximum hang time for closed-system enteral formulas

Answer 788

48 hours (or based on manufacturer’s guidelines)

Question 789

A 74 year old male with history of Alzheimer’s dementia and dysphagia requires enteral nutrition as his sole source of nutrition. He presents to the hospital with a fever, hypotension, poor skin turgor an dry mucous membranes. He is 5 feet 9 inches tall and 67 kg. He is currently getting 1200mL of free water daily from the EN + 400 mL from free water flushes. His estimated calorie needs are 1800 kcals/day. How should his fluid needs be estimated?

Answer 789

30mL per kg of body weight as using mL /kcal is NOT appropriate and can lead to overhydration

Question 790

what are three methods for estimating fluid needs in enterally fed patients

Answer 790

1mL per kcal of enteral feeding (<65 years old)
Weight based (25-35kcal/kg) for adults > 65 years old
Holliday-Segar Method (1500mL for the first 20 kg and 15mL/kg for each kg remaining over 20kg)

Question 791

how is the Holliday-Segar Method calculated in adults

Answer 791

1500mL of fluid for the first 20 kg

add an additional 15ml/kg over 20 kg

Question 792

weight based fluid calculations are not recommended for

Answer 792

patients with cardiac/kidney failure issues as can lead to fluid overload

Question 793

A 56 year old female with dysphagia who is afebrile weighs 60kg, is on a standard 1kcal/mL enteral formula at 180mL/hr for 10 hours nightly. What volume of water flushes would best meet her daily estimated fluid requirements

Answer 793

1mL/kcal = 1800 mL of total water needed (same as 30mL x 60 kg of water = 1800mL)
Tube Feed Volume + 180mL/hr x 10 hours = 1800 mL, a 1mL/kcal formula contains 84% water, so 1800 x0.840 is approx 1500mL so 1800mL - 1500 mL from tube feed leaves over 300 mL of water for free water flushes

Question 794

Adult, afebrile patients who are enterally fed can have their fluid needs calculated by

Answer 794

1mL or 30-40mL/kg

Question 795

Standard enteral formulas that are 1mL/kcal contain ____% water

Answer 795

84%

Question 796

what are the benefits of starting early, appropriate enteral feedings

Answer 796

decreased bacterial translocation in the gut
preserves gut mucosal lining to decrease infection risk
decreases atrophy of the intestinal villi

Question 797

lack of feeding via the gut during critical illness may lead to ____ of the intestinal villi, predisposing a patient to _____, increased gut ___ and potentially increased ____ risk

Answer 797

atrophy
bacterial translocation of the gut
increased gut permeability
increased infection risk

Question 798

A patient is receiving EN during her 2nd trimester of pregnancy. Nutrition assessment data reflects an average maternal weight gain of 0.42 pounds a week, normal fetal growth, an albumin of 0.2 g/dL and a nitrogen balance of +2 grams a day. based on the data provided, which parameters are useful in assessing efficacy of enteral nutrition in pregnancy. Which ones are not?

Answer 798

Good indicators: maternal weight gain, fetal growth

Poor indicators: albumin, protein

Question 799

what are the most important factors in assessing adequacy and efficacy of enteral nutrition in pregnancy?

Answer 799

fetal growth & maternal weight gain

Question 800

there is a strong correlation between infant birth weight and ______ weight

Answer 800

maternal

Question 801

a positive nitrogen balance indicates adequate

Answer 801

protien provision

Question 802

A diabetic patient with early satiety, bloating, occasional vomiting & extensive weight loss. After a thorough GI workup, the patient is diagnosed with gastroparesis. What type of EN formula is most efficacious?

Answer 802

concentrated (if sensitive to volume)
standard/polymeric (esp. if given jejunum)
low in fat and fiber to avoid delayed gastric emptying

Question 803

elemental formulas are reserved for patients with

Answer 803

malabsorption and pancreatic insufficiency

Question 804

high protein enteral formulas are reserved for patients with

Answer 804

wound healing and critical care nutrition

Question 805

Lactose is a common ingredient in which type of EN formula?

Answer 805

standard infant formula as it mimics the carbohydrate content found in human milk

Question 806

Most adult medical nutrition products are _____ free because many adults are lactose intolerant, and lactase efficacy is decreased during illness

Answer 806

lactose

Question 807

Patients with chyle leaks will have trouble tolerating polymeric EN formulas becuase

Answer 807

they cannot absorb long chain fatty acids well

Question 808

Elemental EN formulas contain individual _____ and 2-3% of calories from these types of fats ______

Answer 808

amino acids

long chain fatty acids

Question 809

Patients with chyle leaks need to decrease the quantity and duration of chyle loss using ___ formulas and a ______ diet

Answer 809

elemental

low fat

Question 810

patients with Chron’s or Celiac Disease usually do well with intact macronutrients true or false

Answer 810

true

Question 811

patients with gastroparesis can usually tolerate polymeric enteral formulas especially wehn

Answer 811

they are provided in the jejunum

Question 812

In patients with pancreatitis, which parameters are important in predicting tolerance of enteral feedings?

Answer 812

APACHE II Score
Duration of NPO
Abdominal pain

Question 813

What is the most influential factor to determine tolerance of enteral nutrition in pancreatitis

Answer 813

disease severity as measured by APACHE II Score

Question 814

A duration of NPO > _____ days has indicated poor tolerance to EN in studies for pancreatitis

Answer 814

6 days

Question 815

Increased ______ is a clinical indication of enteral feeding intolerance in patients with pancreatitis

Answer 815

abdominal pain

Question 816

what is the rationale for starting EN

Answer 816

it may be started in patients who cannot or will not eat adequately

Question 817

Prior to starting EN, what should be considered

Answer 817

ethics
patient & family wishes
quality of life
risks & benefits
clinical status
prognosis

Question 818

EN should be started when patients are expected to or have not had adequate oral intake for ______ days

Answer 818

7-14 days

Question 819

EN should not be initiated if the expected duration is less than ____ days in the malnourished patient or less than ____ days in an adequately nourished pateint

Answer 819

5-7 days (malnourished)

7-10 days (adequately nourished)

Question 820

EN should only be started when the patient is

Answer 820

fully resuscitated or stable

Question 821

What is the preferred method of nutrition for open abdomen

Answer 821

enteral

Question 822

when should PN be started in open abdomen when

Answer 822

EN isn’t tolerated for greater than 7 days

Question 823

PN is indicated in high output mid-jejunal fistula, intractable obstipation & vomiting and short bowel syndrome with < _______ cm and without a ______

Answer 823

<50 cm w/ out a colon

Question 824

what are common indications to place a gastro-jejunostomy tube?

Answer 824

diabetic gastroparesis as it bypasses the stomach to prevent nausea, vomiting during feeding

Question 825

Skin level or low profile enteral access devices have what desire features?

Answer 825

more comfortable
more cosmetically pleasing
can be capped when not in use

Question 826

what are cons of low profile enteral access devices

Answer 826

they require an access connector to provide meds or feedings & requires manual dexterity

Question 827

what is the gold standard for determining proper position of a feeding tube placed at the bedside?

Answer 827

radiographic confirmation

Question 828

do auscultation, pH testing, aspiration still require cxr

Answer 828

yes

Question 829

placement of a jejunostomy feeding tube would NOT be beneficial in _____ as it would increase stool output , decreased absorption

Answer 829

short bowel syndrome

Question 830

what are uses for jejunostomy

Answer 830

gastroparesis, pancreaticduodenectomy (whipple), chronic pancreatitis

Question 831

for patients with short bowel syndrome what type of enteral feeding is recommended

Answer 831

slow, continuous infusion in the stomach to maximize absorption and intestinal transit time

Question 832

compared to gastric feeding, small bowel feeding is associated with which of the following outcomes in critically ill patients

Answer 832

increased nutrient delivery, reduced GRV and reflux, shorter time to get to target goal

Question 833

what intervention may assist with the appropriate placement of a nasogastric feeding tube in an alert patient?

Answer 833

elevated the HOB
have the patient in a sitting position
take small sips of water

Question 834

what is most likely to facilitate transpyloric placement of a nasoenteric feeding tube

Answer 834

fluoroscopy & endoscopy or bedside electromagnetic imaging system

Question 835

what are contraindications for the placement of a PEG in a patient with liver disease

Answer 835

ascites (it may prevent the gastric and abdominal wall from being in close proximity so the trocar won’t be able to pass through the stomach wall with a poor seal possibly leading to peritonitis

Question 836

what are POSSIBLE contraindications to PEG tube placement when risk vs. benefit should be evaluated

Answer 836

esophageal & gastric varices
coagulopathy
hepatic encephalopathy
fulminant hepatic failure
portal HTN

Question 837

What is an advantage of a gastrostomy feeding tube compared to an NG tube

Answer 837

gastrostomy tubes can be used in long term needs

Question 838

When EN is needed for over 4 weeks what type of feeding tube is preferred

Answer 838

gastrostomy

Question 839

do gastrostomy tubes decrease the risk of aspiration

Answer 839

no, but the due have an increased risk of gastric perforation

Question 840

Ascites is considered a relative contraindication to PEG tube as it increases the risk of

Answer 840

peritonitis

Question 841

A patient with a traumatic brain injury will require enteral nutrition for three weeks. What is the preferred method of feeding tube placement

Answer 841

naso-enteric

Question 842

what are the risks of an open feeding tube, laparoscopic feeding tube and endoscopic feeding tube placement

Answer 842

bleeding, anesthesia, bowel perforation , infection

Question 843

What is the primary advantage of a direct percutaneous endoscopic transgastric placed jejunal (PEG-J) tube vs a a PEJ

Answer 843

the PEG-J has a decreased risk of migration into the stomach

Question 844

placement of a percutaneous endoscopic _____ tube increases the risk of developing a gastric outlet obstruction

Answer 844

PEJ tube

Question 845

What characteristic of EN formulas is MOST likely to increase splanchnic blood flow in a critically ill patient?

Answer 845

high fat enteral formulas

Question 846

high fat enteral nutrition helps promote what in a critically ill patient

Answer 846

blood flow to the bowel is maxamized

Question 847

what type of enteral nutrition formula is ideal for patients at high risk for intestinal ischemia, as adequate bowel perfusion is needed for tolerance of high fiber, high osmolarity

Answer 847

isotonic, fiber free

Question 848

Hospital prepared enteral nutrition formulas should be stored at approximately what temperature

Answer 848

4 degrees C to 39 degrees F

Question 849

what is considered the danger zone for food contamination

Answer 849

5-57 decrees C

Question 850

A 60 year old female is admitted with a stroke and fails a swallowing evaluation. An NG tube is placed and the MD requests an isotonic formula. What calorie density of EN formulas is isotonic

Answer 850

1 kcal/mL which is about 300 mOsm/kg

Question 851

what is the range of osmolarity for 1kcal/mL EN formulas

Answer 851

300-350 mOsm/kg

Question 852

what is the range of osmolarity for 1.2 kcal/mL EN formulas

Answer 852

400-450 mOsm/kg

Question 853

what is the range of osmolarity for 1.5 kcal/mL EN formulas

Answer 853

500-650 mOsm/kg

Question 854

what is the range of osmolarity for 2 kcal/mL EN formulas

Answer 854

700-800 mOsm/kg

Question 855

what is the best initial enteral feeding regimen for a critically ill adult

Answer 855

full strength started at a low rate and slowly advance to goal

Question 856

why is it not encouraged to dilute enteral formulas

Answer 856

it can cause microbial growth and inadequate nutrition provision

Question 857

What is the most important intervention to decrease the risk of pulmonary aspiration during gastric tube feedings

Answer 857

elevated the HOB 30-45 degrees

Question 858

drugs that cause diarrhea are due to their

Answer 858

hypertonicity, laxative action from sorbitol or magnesium containing products

Question 859

what are drugs/medications that are known to cause diarrhea

Answer 859

medications containing sorbitol, magnesium citrate, antibiotics that cause enteritis, high TF osmolarity/bolus (sometimes)

Question 860

tube feeding is often held 2 hours before and after enteral administration of these types of meds

Answer 860

warfarin
ciprofloxacin
phenytoin
carbamazepine
fluoroquinolones

Question 861

what strategies can be employed to reduce the risk of feeding tube occlusion

Answer 861

flush with water before and after each medication

Question 862

drugs that are microencapsulated with beads or pellets are most effectively administrated through large bore feeding tubes when mixed with _______ due to the acidity to reduce the beads/pellets from sticking to the tube. The tube should also be flushed with water before and after the OJ and separately from the EN formula. Don’t use warm water.

Answer 862

orange juice

Question 863

what type of enteral formulas are least likely to be contaminated with microorganisms

Answer 863

ready to hang

Question 864

what is the hang time of formula made from reconstituted powder

Answer 864

4 hours

Question 865

what is the hang time of home made blenderized enteral formulas

Answer 865

2 hours

Question 866

what is the hang time of commercially made blenderiezed enteral formulas

Answer 866

4-8 hours

Question 867

A 45 year old male is admitted with stage 4 pressure wounds, sepsis and acute respiratory failure who requires mechanical ventilation. BUN is stable, no additional excessive GI losses are noted. A polymeric high protein EN formula was started on day 1 of admit. On day 7, the primary care team requested an eval of the protein dose provided by EN. The EN formula gives 136 grams of protein (1.5g/kg/day). What is the best method to assess protein adequacy

Answer 867

nitrogen balance study

Question 868

_____ is the gold standard for assessing the adequacy of protein intake in the acute hospital setting

Answer 868

nitrogen balance

Question 869

Nitrogen balance is the difference of

Answer 869

nitrogen intake -nitrogen output

Question 870

nitrogen output as part of a nitrogen balance study is measured from

Answer 870

urine urea nitrogen from a 24 hour urine collection

Question 871

nitrogen intake as part of a nitrogen balance study is measured from

Answer 871

EN or PN intake

Question 872

what are limitations to using a nitrogen balance study

Answer 872

renal dysfunction, errors estimating output and intake

Question 873

Use of a semi-elemental or elemental formula in place of a polymeric formula should be considered with

Answer 873

intolerance to polymeric formula

Question 874

Use of immune modulating formula may be beneficial in

Answer 874

elective surgery, TBI, abdominal and torso injury from a MVA crash

Question 875

immune modulating formulas contain

Answer 875

arginine, glutamine, nucleotides, omega 3 fatty acids

Question 876

the use of immune modulating formulas is not recommended for routine use

Answer 876

use is controversial, there are inconsistent outcomes and contraindicated in septic patients 2/2 adverse effects with arginine

Question 877

what would be the most appropriate TF formula for a patient with extensive second degree burns

Answer 877

high protein

Question 878

high protein EN formulas are needed in severe burns because

Answer 878

burns cause a breakdown of lean muscle for energy and loss from wounds

Question 879

What are types of modular products for EN

Answer 879

MCT Oil
Glucose
Fiber
Protein

Question 880

what are EN modulars used for

Answer 880

to fortify EN regimens or meals

Question 881

EN modulars should not be added directly to

Answer 881

enteral formula

Question 882

Early initiation of EN has been a suggested benefit LICU patients by reduction infectious complications, length of stay and possibly decreased mortality. Which group of patient’s might be at significant risk from early EN.

Answer 882

patients with increased vasopressor support which may increase the risk of intestinal ischemia from decreased blood perfusion

Question 883

a patient with ARDS getting EN will benefit most from

Answer 883

avoidance of overfeeding

Question 884

this disease is associated with inflammation causing alveolar damage and lung capillary endothelial injury

Answer 884

ARDS

Question 885

Formulas with omega 3’s are thought to be used for ARDS because

Answer 885

the omega 3 fatty acids, arginine, and glutamine may down regulate the inflammatory response induced by ARDS

Question 886

immune modulating formulas with omega 3 fatty acids are not recommended for routine use in ARDS because

Answer 886

research remains inconclusive

Question 887

The use of EN formulas enriched with branched-chain amino acids may benefit with

Answer 887

refractory encephalopathy

Question 888

Theory: liver failure is thought to increase the ratio of aromatic amino acids (AAA) to branched chain amino acids (BCAAs). BCAAs also decrease from muscle breakdown. Increased AAAs develop “fake neurotransmitters” causing encephalopathy. Only use formulas with increased BCAAs if a patient is still encephalopathic despite medicine

Answer 888

encephalopathy

unresponsive to standard medical therapy

Question 889

EN may be contraindicated in early post transplant period with hematopoietic cell transplants because of

Answer 889

potential mucosal toxicities r/t conditioning regimen that causes to GI toxicities that cause, nausea, vomiting, delayed gastric emptying, diarrhea within the first 2-3 weeks of post stem cell transplant may provide EN

Question 890

in patients with early post transplant period with hematopoietic cell transplants what form of artificial nutrition is recommended

Answer 890

there is insufficient data to establish the benefits of enteral nutrition over parenteral nutrition for hematopoietic cell transplants

Question 891

which medication would be appropriate to crush and deliver via enteral nutrition tube

Answer 891

immediate release

Question 892

____ medications should not be crushed to be put through a feeding tube as can cause medication toxicity

Answer 892

slow release 
typical abbreviations (XL, XR,SR,CD)

Question 893

which describes an optimal method of preparing and administering meds via enteral tube

Answer 893

flush the tube with water before and after each medication

Question 894

in patients with severe acute pancreatitis, EN has been documented to provide the following benefits over parenteral nutrition

Answer 894

EN will decrease infection rate, decrease length of stay and decrease mortality

Question 895

In a pt with fat malabsorption of an enteral products containing which of the following concentrated source of energy

Answer 895

MCT’s; they are absorbed directly into the blood stream into the portal circulation by passing need for pancreatic enzymes, bile carnitine dependent transport into the mitochondria