chapter 15 book notes Flashcards
1
Q
specialized nutrition support:
A
- the delivery of nutrients using a feeding tube or intravenous infusions,
2
Q
enteral nutrition:
A
- the provision of nutrients using the GI tract;
-“tube feedings”
3
Q
parenteral nutrition:
A
-the intravenous provision of nutrients that bypasses the GI tract.
-2 types: by peripheral vein & central vein
4
Q
oral nutrition support:
A
-nutrition care that allows a malnourished patient to meet nutritional requirements by
mouth
-GI function is normal and poor appetite is the primary nutrition problem.
5
Q
Medical conditions/treatments that may indicate the need for tube feedings: (5)
A
-severe swallowing disorders
-impaired motility in the upper GI tract
-GI obstructions and fistulas
-mechanical ventilation
-certain types of intestinal surgeries
6
Q
fistulas:
A
-abnormal passages between organs or tissues that permit the passage of secretions
7
Q
Complications due to tube feedings:
A
-severe GI bleeding
-high output fistulas
-uncontrollable vomiting or diarrhea
8
Q
The tube feeding route chosen depends on the
A
-patient’s medical condition,
-the expected duration of tube feeding,
-the potential complications of a particular route.
9
Q
When a patient is expected to be tube fed for less than four
weeks, the feeding tube is generally routed into the GI tract via the ??
A
-nose
-nasogastric (entered in nose and tube stops in stomach) or nasointestinal( tube enter nose and stops in small intestine) routes
10
Q
Is the patient usually awake during transnasal placement of the feeding tube?
A
-yes
11
Q
3 different transnasal feeding tube placements:
A
-nasogastric route (nose to stomach)
-nasoduodenal route (nose to duodenum)
-nasojejunal route (nose to jejunum)
12
Q
If the patient is awake and alert, he or she can swallow ?? to ease the tube’s passage
A
-water
13
Q
The final position of the feeding tube tip is verified by…
A
-X-ray or by other means
14
Q
What is the best feeding tube route for infants?
A
-orogastric (through the mouth to the stomach)
-allows infant to breather more normally during feedings
15
Q
When is direct tube route to the stomach or intestines used?
A
-if patient will be tube fed for longer than 4 weeks or
-if the nasointestinal route is inaccessible due to an obstruction or other medical reasons
16
Q
2 types of enterostomy:
A
-gastrostomy (opening in abdominal wall that leads to the stomach)
-jejunostomy (opening in abdominal wall that leads to jejunum.
17
Q
What kind of feeding is always preferred whenever possible and why? Either directly into stomach or intestines?
A
-gastric feedings
-more easily tolerated and less complicated to deliver than intestinal feedings because the stomach controls the rate at which nutrients enter the intestine.
18
Q
When are gastric feedings not possible? (3)
A
-gastric obstruction
-motility disorders that interfere with stomach emptying
-inadequate stomach volume due to surgery
19
Q
Gastric feedings are also avoided in patients at high risk of ???
A
-aspiration
-common complication in which substances from the GI tract are drawn into the lungs potentially leading to aspiration pneumonia
20
Q
What are feeding tubes made of?
A
-soft, flexible materials & come in variety of lengths and diameters
-usually silicone, polyurethane, polyvinyl chloride
21
Q
The tube selected largely depends on the patient’s
A
- age and size,
-the feeding route,
-the formula viscosity
22
Q
In many cases, the tube selected is the smallest-??
tube through which the formula will flow without ??
A
-diameter
-clogging
23
Q
The outer diameter of a feeding tube is measured in ?? units, in which each unit
equals ?? millimeter
A
-french
-⅓
24
Q
EX: a “12 French” feeding tube has a ?? millimeter diameter
(12 times ⅓ mm = ?? mm)
A
-4
25
The inner diameter depends on the ?? of the tubing
material.
-thickness
26
double lumen tubes:
-a single tube is used for intestinal feedings and gastric decompression
27
gastric decompression:
-stomach contents of patients with motility disorders or obstructions are removed by suction.
28
main types of enteral formulas include the following:
-standard formulas
-elemental formulas
-specialized formulas
-modular formulas
29
standard formulas
-polymeric formulas/ blenderized formulas
-provided to individuals who can digest and absorb nutrients without difficulty
30
What do standard formulas contain?
-intact proteins extracted from milk or soybeans (protein isolates)
-carb sources include hydrolyzed cornstarch, glucose polymers and sugars
31
Elemental formulas
-hydrolyzed/ chemically defined formulas
-prescribed to patients who have compromised digestive or absorptive functions
32
What do elemental formulas contain?
-proteins and carbs that have been partially or fully broken down to fragments that require little digestion.
-low in fat and may provide fat from medium chain triglycerides
33
Specialized formulas
-disease specific/ specialty formulas
-meet the nutrients needs of patients with particular diseases (kidney, liver, and lung)
-very expensive and effectiveness is controversial
34
Modular formulas
-created from individual macronutrient preparations called modules,
-sometimes prepared for patients who require specific nutrient combinations.
-vitamins and minerals preparations can be included.
35
Macronutrient composition of eternal formulas: (fat, carbs, protein)
-protein= 15 to 20% of total kcals
-carbs= 45 to 60% of total kcals
-fat= 30 to 40% kcals
36
what patients benefit from high energy density formulas and which benefit from low energy density?
-low=patients with average fluid requirements
-high=patients with high nutrient needs/ fluid restrictions
37
osmolality:
-the concentration of osmotically active solutes in a solution
-Osmotically active solutes affect osmosis, the movement of water across semipermeable
membranes.
38
An enteral formula with an osmolality similar to that of blood serum (about 300 milliosmoles per kilogram) is an ?? formula, whereas a ?? formula has an osmolality greater than that of blood serum
-isotonic
-hypertonic
-MOST PEOPLE CAN TOLERATE BOTH FEEDINGS W/O DIFFICULTY
39
Most enteral formulas have osmolalities between ?? and ?? milliosmoles per
kilogram
-280 to 875
40
When ?? are infused along with
enteral feedings, however, the osmotic load ?? substantially and may contribute
to the ?? experienced by many tube-fed patients.
-medications
-increases
-diarrhea
41
Factors that influence formula selection include: (5)
-GI function
-nutrient and energy needs
-fluid requirements
-need for fiber modifications
-individual tolerances (food allergies and sensitivities)
42
Nearly all formulas are:
-lactose-free and gluten-free
43
Before starting a tube feeding, health practitioners can ease fears by fully
-discussing the procedure with the patient and family members
44
To minimize the risk of incorrect tube placement, clinicians verify the position of the feeding tube,
-usually with an X-ray, before a feeding is initiated
45
After the tube’s placement has been confirmed, the nurse often secures the tube to the patient’s
-nose and cheek with tape and monitors the position of the tubing throughout the day
46
Tube placement can also be monitored by testing the ?? of a sample of bodily fluid drawn into the feeding tube, as the pH in the stomach (?? or ?? ) is lower than the pH in the small intestine or respiratory tract (?? or ??).
-Ph
-5 or lower
-6 or higher
47
To reduce the risk of aspiration, the patient’s upper body is elevated to a ??- to
??-degree angle during the feeding and for ??to ??minutes after the feeding whenever possible
-30 to 45 degree angle
-30 to 60 minutes
48
the personnel involved with preparing or delivering formula must follow the
specific protocols at their facility that prevent formula contamination, referred to as
-Hazard Analysis and Critical Control Points (HACCP) systems.
49
Formulas may be delivered using either an:
--open feeding system or a closed feeding system
50
Open system
-formula needs to be transferred from its original packaging to a feeding container
51
Closed system
-lees likely to become contaminated, require less nursing time, and can hang for longer periods of time
-more costly, but in long run will save money from preventing bacterial contamination.
52
Clinicians should carefully ??? and put on ??? before handling formulas and feeding containers
-wash hands
-disposable gloves
53
The following steps can reduce the risk of formula contamination when using open
feeding systems:
-clean the lid of can with disposable alcohol wipe and wash can opener with detergent and hot water
-hang no more than 8hr supply of formula (4hr for newborn) when using liquid formula.(formulas from powders or modules hang no longer than 4 hours)
-if not whole can is used label it with date and time and refrigerate right away.
-discard all opened containers not used in 24 hours
54
A new feeding container and
tubing (except for the feeding tube itself) is necessary every ?? hours
-24
55
Nutrient needs may be met by delivering relatively large
amounts of formula several times per day called?? or
smaller amounts continuously ??
-intermittent feedings or bolus feedings)
-(continuous feedings or cyclic feedings)
56
Intermittent feedings:
-similar to usual eating pattern and allow patient freedom of movement between meals
-best tolerated when given to stomach
-uses gravity drip method or infusion pump
57
Bolus feeding
-given every 3 to 4 hours using a syringe
-convenient for patients and staff because they are rapidly administered
-do not require an infusion pump, and allow greater
independence for patients.
58
Disadvantages to bolus feedings:
-abdominal discomfort,
-nausea,
-cramping
-risk of aspiration is greater
59
Continuous feedings
-delivered slowly and constant rate over a period of 8 to 24 hours
-preferred method of intestinal feedings
-infusion pump used
-more costly and limit a persons movement
60
What kind of patients are continuous feedings recommended for?
-critically ill patients or patients that cannot tolerate intermittent feedings
61
Cyclic feedings
-continuous feedings conducted for shorter periods of time
-8 to 18 hours
62
Is diluting formulas recommended?
-NO
-formulas are typically provided in full strength
63
gastric residual volume:
-the volume of formula and GI secretions remaining in the stomach after a
previous feeding.
64
gastric residual volume is useful in patients who have undergone...
-abdominal surgery or who exhibit signs of feeding intolerance (nausea and abdominal distention)
65
In such patients, tube feedings may be withheld
and an evaluation conducted if the gastric residual volume exceeds ??? milliliters on
two consecutive checks.
-500
66
If the tendency to accumulate fluids persists, the physician
may recommend intestinal feedings or begin
-drug therapy to stimulate gastric emptying.
67
patients require about ?? to ?? milliliters of water per kilogram of body weight daily
-30 to 40
68
most enteral formulas contain about ?? to ??percent water, or about 700 to 850 milliliters of water per liter of formula
-70 to 85
69
Water can also be administered through...
-water flushes
-initially conducted to prevent feeding tubes from clogging and add to patients water intake.
70
some medications may need to be exposed to the ?? stomach environment
and thus cannot be administered via an ?? feeding tube
-acidic
-intestinal
71
Medications can also cause feeding tubes to ??
-clog
72
Continuous feedings are ordinarily stopped before and after medication administration to prevent
-interactions that may clog the feeding tube or interfere with the medication’s absorption
73
Some medications may require a prolonged formula-free interval; for example,
-feedings need to be stopped for at least one hour before and after administering phenytoin, a medication that controls seizures
74
Medications are a major cause of ?? that frequently accompanies
tube feedings
-diarrhea
75
Common tube feeding complications: (6)
-aspiration of formula
-clogged feeding tube
-constipation
-diarrhea
-fluid and electrolyte imbalances
-nausea, vomiting, cramping
76
patients with the following conditions are often considered candidates for
parenteral nutrition:
-paralytic ileus (intestinal paralysis)
-short bowel syndrome (part of small intestine has been removed)
-bone marrow transplants
77
The access sites for intravenous nutrition fall into
two main categories
-peripheral veins: located in forearm or hand, used in short periods of time
-central veins: located near heart, needed for longer periods of time
78
Peripheral veins can be damaged by overly concentrated solutions, developing ...
-phlebitis= inflammation of peripheral veins
79
To prevent phlebitis, the osmolarity of
parenteral solutions used for PPN is generally kept below ?? milliosmoles
per liter,
-900
80
PPN is used most often in patients who require short-term nutrition support
(less than ?? weeks) and patients who do CPN need…
two
-high nutrient needs or fluid restrictions
81
Central parenteral nutrition relies on larger...
-central veins where blood volume is greater and nutrient conc. do not need to be limited.
82
Because the central
veins carry a large volume of blood, the parenteral solutions are rapidly ??
and therefore patients with high nutrient needs or fluid restrictions can receive the
nutrient-dense solutions they require
-diluted
83
The ?? located within health care institutions are often responsible for
preparing parenteral solutions
-pharmacies
84
Commercial amino acid solutions contain a mix of essential and
nonessential amino acids and are available in concentrations between ?? and ??percent
-3 to 20%
85
the more concentrated solutions (??percent and higher) are most
often used for preparing parenteral solutions
-8.5
86
What is the main source of energy in parenteral solutions? in the form of??
-glucose in the form of dextrose monohydrate where each glucose molecule is associated with a single water molecule
87
Dextrose monohydrate provides ??
kcalories per gram
-3.4
88
Lipid emulsions supply essential ?? and are a significant source of
??
-fatty acids
-energy
89
Most emulsions available in the United States contain
triglycerides from either
-soybean oil or a mixture of olive oil and soybean oil
90
Lipid emulsions are often provided daily and may supply about ?? to ??
percent of total kcalories
-20 to 30
91
Including lipids as an energy source reduces the
need for energy from ??and thereby lowers the risk of ??in
glucose-intolerant patients
-dextrose
-hyperglycemia
92
lipid emulsions that
supply excessive amounts of ?? acid (such as the amount contained in soybean
oil) may aggravate some ?? conditions
-linoleic acid
-inflammatory
93
Daily fluid needs range from ??? to ?? milliliters per kilogram of body weight in stable adult patients, averaging between about ??? and ???
milliliters for most people
-30 to 40
-1500 to 2000
94
The electrolytes added to parenteral solutions include (6)
-sodium, potassium, chloride,
calcium, magnesium, and phosphate
95
what vitamin is excluded in parenteral solution when warfarin is used?
-vitamin K
96
What mineral is excluded from parenteral solution? and why?
-iron
-because it can destabilize parenteral solutions that contain lipid emulsions and because some patients have allergic reactions to infused iron
97
piggyback:
-the administration of a
second solution using a separate
catheter.
98
Medications that are compatible with parenteral solutions:
-insulin
-H2 blockers
-certain antibiotics
99
total nutrient admixture (TNA):
-a parenteral solution that contains dextrose, amino acids, and lipids;
-also called a 3-in-1 solution or an all-in-one solution.
100
2-in-1 solution:
-a parenteral solution that contains dextrose and amino acids, but not lipids.
-lipid emulsion must be administered separately, often by piggyback administration
101
administration of TNA solutions is simpler because only ?? infusion pump is required, the addition of lipid emulsion to solutions may ?? their stability, potentially resulting
in the formation of
-one
-reduce
-enlarged lipid droplets that can obstruct capillaries or have other damaging effects.
102
Thus, lipids are often administered separately when
they are not a major
-energy source and are used only to provide essential fatty acids
103
Although skilled nurses
can place catheters into ?? veins, only qualified physicians can
insert catheters directly into ?? veins.
-peripheral
-central
104
Ways to reduce complications when inserting catheters:
-use aseptic techniques
-change tubing
-change dressing that covers the catheter site
105
Patients who require long-term parenteral nutrition often receive infusions for ?? - to ??-hour periods only called?
- 8 to 14
- (cyclic parenteral nutrition)
-allow more freedom of movement for patient
106
metabolic complications that may
result from parenteral nutrition: and efforts to fix them
-hyperglycemia (provide insulin with feeding)
-hypertriglyceridemia
-refeeding syndrome
-liver disease (fatty liver results from parenteral nutrition, avoid giving excess energy (dextrose and lipids which promote fat deposit in liver)
-gallbladder disease (medication to stimulate gallbladder contractions or improve bile flow)
-bone disease (medication, weight bearing PA)
107
Most patients prefer what home enteral nutrition access?
-gastrostomy or jejunostomy tubes because they allow a more normal lifestyle
-bolus feedings are best
108
Most patients must do what home parenteral nutrition access?
-central
-because long term therapy must meet all of a patients nutrient needs and needs access to central vein, usually by chest wall.
109
Because ?? are
required for home parenteral nutrition, sufficient ??? backup is necessary in case
electrical service is interrupted
-infusion pumps
-battery
110
What is a good source of current information
and emotional support for individuals who require home nutrition support
- The Oley Foundation (oley.org)
