EN Monitoring and Disease Specific Nutrition Support

Question 1

Which of the following feeding schedules would be most appropriate for a patient with labile and poorly controlled blood glucose concentrations?

1. Bolus
2. Continuous
3. Gravity drip
4. Nocturnal infusion

Answer 1

2. Continuous
   A continous infusion may facilitate more steady and predictable blood glucose concentration. Intermittent feeding schedules, such as bolus, gravity drip, or nocturnal infusion, cause fluctuations in blood glucose concentrations, making them more difficult to control

Question 2

Which of the following individuals would best benefit from intermittent tube feeding?

1. status post CVA who has initiated oral foods during the day
2. critically ill motorcycle accident victim in the ICU
3. Knee replacement patient in rehab facility with scheduled therapies
4. post-operative bowel surgery patient who has an ileum.

Answer 2

1. S/P CVA who has initiated oral foods during the day.
   Intermittent feedings are generally an amount of 200-300ml administered over 30-60 minutes every 4-6 hours. A patient who is transitioning from tube feeding to an oral diet can benefit from the use of intermittent nocturnal tube feeding. The critically ill pt in more likely to require continuous feeding. The knee replacement pt is unlikely to require nutrition support and the post-op pt with ileum may require PN depending upon the length of time without enteral support.

Question 3

In order to prevent the development of tube feeding syndrome, which of the following are recommended fluid and protein loads?

1. Fluid of 1 ml/kcal and protein load not to exceed 1.5 g protein/kg desirable body weight
2. Fluid of 1 ml/kcal and protein load not to exceed 2 g protein/kg desirable body weight
3. Fluid of 1.5 ml/kcal and protein load limited to 0.6 g/kg desirable body weight
4. Fluid of 1.5 ml/kcal and protein load limited to 0.8 g/kg desirable body weight

Answer 3

1. Fluid of 1 ml/kcal and protein load not to exceed 1.5 g protein/kg DBW
   Tube feeding syndrome may include azotemia, hypernatremia, and dehydration that result from the use of high protein tube feeding with a high renal solute load, typically with inadequate fluid (at least 1 ml/kcal plus replacement for any respiratory, GI or renal losses)

Question 4

Which of the following best describes the addition of blue dye to enteral feeding?

1. It prevents aspiration of enteral formula
2. Its use in detection of aspiration is highly sensitive
3. It should be added only in small amounts
4. It is no longer recommended for the detection of aspiration of enteral formula

Answer 4

4. It no longer recommended for the detection of aspiration of enteral formula.
   The addition of blue dye to enteral feedings was a common practice in the past to help detect aspiration of formula. The use of blue dye in detecting aspiration of formula has a low sensitivity. Several reports of systemic toxicity, some resulting in death, have been published in recent years. As a result the DS FDS removed FD and C Blue #1 from the market in 2003.

Question 5

What is the enteral feeding method in which 240-400 ml of formula flow into the stomach by gravity through the barrel of a 60 ml syringe attached to the end of the feeding tube?

1. Gravity drip feeding
2. Cyclic feeding
3. Bolus feeding
4. Continous infusion feeding

Answer 5

3. Bolus feeding
   Bolus feeding is the simplest way to deliver gastric feeding and is popular with home care pt. Gravity drip is a variation of bolus feeding in which an administration set or bag delivers the enteral formula over a period of 30-60 minutes.

Question 6

An example of the method of feeding is the infusion of a predetermined volume of formula over 12 hours

1. bolus
2. cyclic
3. continuous
4. needle catheter

Answer 6

2. Cyclic

cyclic feedings are generally administered over 8-20 hours per day

Question 7

Which of the following types of feeding delivery methods is most commonly used for its with a jejunal feeding tube.

1. bolus feeding
2. gravity feeding
3. intermittent feeding
4. continous pump feeding

Answer 7

4. continuous pump feeding
   Jejunal feeding is usually delivered by continuous pump to minimize the chance of diarrhea and abdominal bloating. Gastric feeding can be given by bolus or intermittent gravity methods. This is because the stomach serves as a reservoir thus delaying the rapid emptying of formula into the small bowel.

Question 8

Which of the following methods of enteral nutrition delivery is most commonly used in hospitalized pts?

1. bolus feeding
2. cyclic feeding
3. intermittent feeding
4. continuous infusion

Answer 8

4. Continuous infusion
   There are several factors related to the favorable use of continuous infusion feeding in the hospitalized pt. These include accessibility of enteral pumps to control the rate and volume of formula delivered to the pt, better tolerance to tube feeding with fewer gastric complaints, and possible lowered risk of aspiration by prevention of gastric distention.

Question 9

Which of the following is most likely to be a benefit of a closed system enteral system?

1. less costly
2. shorter hang time
3. ability to develop modular feedings
4. less nursing time required for administration

Answer 9

4. Less nursing time required for administration
   Closed enteral feeding systems are purchased as bags already pre-filled with the formula. No changes can be made to the formula. It is less susceptible to microbial contamination, has a longer hang time, and requires less nursing time.

Question 10

Which of the following is a potential advantage of using an open system for delivery of tube feeding?

1. less nursing time
2. longer hang time
3. less contamination
4. less formula wastage

Answer 10

4. less formula wastage
   open systems may not waste as much as compared to closed systems that are packaged in 1 L volumes or greater. In open system feedings, bags must be filled with enteral formula. Due to the higher risk of microbial contamination, hang time should be limited to 8-12 hours. The shorter hang time requires additional nursing intervention in preparing enteral formulas to be administered to the pt.

Question 11

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

1. 30% of nutrient intake
2. 40% of nutrient intake
3. 50% of nutrient intake
4. 60% of nutrient intake

Answer 11

4. 60% of nutrient intake
   While there is no clinically proven points at which tube feeding should be discontinued with adequacy of oral intake, a general guideline established by ASPEN is that oral intake should meet at least 60% of nutrient intake or the determination could be based on clinical judgment

Question 12

In addition to a physical exam, which of the following is an appropriate clinical measurement that can be performed at the bedside to assess gastric emptying.

1. Radionuclide scintigraphy
2. Paracetamol absorption test
3. Measurement of gastric reflux
4. Measurement of gastric residual volume

Answer 12

4. Measurement of gastric residual volume
   Although other methods to assess gastric emptying exist including paracetamol absorption test and radionuclide scintigraphy, a practical method in conjunction with physical exam at the bedside is the measurement of GRV. GRV is the measurement most frequently done by nursing personnel for the assessment of gastric emptying. GRV is generally measured every 4-6 hours. When pts are receiving intermittent TF, GRV is measured prior to the scheduled feeding. The significance of GRV is controversial. GRV can be affected by variability in pooling of gastric secretions in relationship to the pt’s position and will not be measured appropriately if the ports of the feeding tube are positioned above the pool of gastric fluid.

Question 13

When administering multiple medications via enteral feeding tubes, medication should be

1. crushed, dissolved, and administered separately, followed by a 15-30 ml water flush
2. mixed together in a 30 ml slurry and flushed together
3. delivered in liquid form without extra water flushed
4. mixed directly into the feeding formulations, delivered by syringe, gravity bag or feeding pump

Answer 13

1. Crushed, dissolved, and administered separately, followed by 15-30 ml water flush.
   Medications should only be administered via feeding tube as a last option. The site of delivery, feeding tube size, and medication absorption and actions should be considered when developing pharmacotherapy plans. Liquid medications are preferred, and should be flushed with water individually to avoid adherence to the feeding tube, causing protein denaturation and tube clogging. Standard tablets can be crushed to form a fine powder and then dissolved or suspended in 30-60 ml water. Enteric-coasted, controlled release, and sustained release medications should not be crushed. Feeding tubes should be flushed with 15-30 ml water before and after drug administration, delivered separately. Medications should not be mixed directly into the enteral formulation. Mixing acidic medications into formula may result in protein denaturation.

Question 14

Which of the following is a major risk factor for aspiration in critically ill patients?

1. gastric residual volume <150 ml
2. decreased level of consciousness
3. age
4. small diameter feeding tube

Answer 14

2. Decreased level of consciousness
   decreased level of consciousness is a major risk factor for risk of aspiration. Other major risk factors include documented previous aspiration, vomiting, tracheal intubation, neuromuscular disease, persistent high GRV, and prolonged supine position. An association between GRV amount and aspiration risk has not been validated. Small bowel feeding should be considered when residual volumes are 250 ml or more on 2 or more consecutive assessments. Age is an additional factor that can increase risk but is not a major factor identifying the risk of aspiration.

Question 15

Which would NOT be appropriate management of hyper granulation around the PEG site?

1. keep the area dry
2. tube stabilizing device
3. occlusive dressing
4. silver nitrate cauterization

Answer 15

3. Occlusive dressing
   Granulation tissue may form within feeding tube tracts and may grow out onto the skin surface. Hyper granulation typically developed when the exit site remains moist or the tube is not stabilized and moves more than 1/4 inch in the stoma. The main concern when granulation occurs is that it can cause even more moisture accumulation under the external bolster, increasing the risk for skin breakdown. Preventative education should stress the need for keeping the area dry and the tube stabilized. An occlusive dressing may promote the retention of moisture at the exit site and therefore should not be used to manage hyper granulation.

Question 16

Which of the following tube feeding orders best reflects the use of an intermittent schedule?

1. polymeric formula 240 ml administered over one hour, 5x per day
2. predigested formula administered at 50 ml/hr over 24 hours
3. 120 ml of a 2 kcal/ml concentrated formula administered over 30 minutes one time per day
4. fiber-containing formula administered at 75 ml/hr over 24 hours.

Answer 16

1. Polymeric formula 240 ml administered over 1 hour 5x per day
   Intermittent feedings are generally an amount of 200-300 ml administered over 30-60 minutes every 4-6 hours, whereas continuous feedings are delivered at a prescribed rate without interruption. Cyclic feedings are generally administered over 8-20 hours per day, depending on the pt’s volume tolerance.

Question 17

Constipation in the enterally fed patient is most often associated with all EXCEPT

1. rapid or bolus infusion
2. obstruction
3. lack of adequate hydration
4. prolonged bed rest

Answer 17

1. Rapid or bolus infusion
   Constipation is a GI complication associated with enteral nutrition and may be cause by lack of adequate hydration, long-term fiber free feedings, prolonged bed rest, impaction, obstruction, and narcotics.

Question 18

When is it appropriate to delay the initiation of tube feeding? When the pt is

1. Hemodynamically unstable
2. at a decreased level of consciousness
3. post-operative day 2
4. scheduled for discharge

Answer 18

1. Hemodynamically unstable
   Early EN is encouraged to attenuate the rapid depletion of nutrient stores after metabolic stress or help maintain normal immune function. EN initiation should be delayed until the pt is fully volume resuscitated, hemodynamically stable, and mesenteric perfusion has been restored to reduce the risk of intestinal ischemia.