EN Overview Flashcards
what are major risk factors for aspiration in critically ill patients
- decreased levels of consciousness
- previous history of aspiration
- vomiting
- tracheal intubation
- neuromuscular disease
- persistent high gastric residual volume
- prolonged supine positioning
- large diameter feeding tube
what is the most appropriate management of hyperagranulation around a PEG tube site
cauterize with silver nitrate
_______ 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
granulation tissue
A tube feeding schedule where formula is provided as 240mL administered over 45 mins 5x/day is known as a __________
intermittent schedule
Tube feeding provided in a volume between 240-480mL given over 45minutes several times a day with or without a pump is called _____ feeding
intermittent feeding
What is the benefit of using an electromagnetic replacement device for NGT placement?
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.
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?
foul smelling drainage
The most common complication soon after PEG or PEJ placement is a
peristomal infection
what type of feeding schedule would be the most appropriate for a critically ill patient with poorly controlled blood glucose
continuous (consistency stabilizes blood sugars)
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
hypo or hyperglycemia
A terminally ill patient at home on hospice complains of nausea during enteral feedings. A decision is made to discontinue the enteral feeding because
- EN feeding and hydration don’t always ensure comfort
- During starvation the body produces ketones which are euphoric
- The most common symptom when nutrition/hydration are withheld is dry mouth, which is alleviated with good oral mouth care
- IV hydration in the terminally ill patient can raise the risk of patient discomfort and respiratory distress
The most common symptom when withholding hydration or nutrition from a terminally ill patient would be _____ and can be alleviated by ________
dry mouth
good oral mouth care
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
are not considered to be at risk to also be added on the protocol
when refeeding, electrolytes should be replete via which route
IV, oral or feeding tube depending on appropriateness
when a patient is at risk for refeeding syndrome, feedings should ________ be delayed but instead __________
don’t delay nutrition feedings
initiate slowly, advance slowly per electrolyte levels and clinical response
Bacterial contamination during enteral feeding can originate from the patients throat, stomach, lungs, feeding equipment, and retrograde contamination from the patient’s own
secretions
the longer an enteral product is hung the _______ the chance of bacterial contamination
higher
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?
check when his last bowel movement was and if the patient is found to be constipated, initiate a bowel regimen
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.
- rapid administration
- hyper-osmolar solutions
- peristalsis
Only hold a tube feeding if a patient’s abdominal girth has extended beyond ____ to ___ cm
8-10
Patients who are alert and cooperative are at the ____ risk of pulmonary injury from small bore feeding tube misplacement
lowest risk
Oral or nasogastric feeding tubes used for EN should only be indicated for use less than ____ weeks
4 weeks
Placement of feeding tubes is complicated in uncooperative patients with anatomic abnormalities and critically ill patients in which ______ is inhibited
swallowing
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?
refer the patient to the gastroenterologist or enterostomal nurse
a new occurrence of pain at or near the tube feeding site of a patient should be promptly evaluated by
the patient’s GI doctor or enterostomal nurse
Constipation in the enterally fed patient may be associated with
obstruction lack of adequate hydration prolonged best rest / lack of activity long term fiber free feedings narcotics
what is most likely the cause of watery diarrhea and bloating in the enterally fed adult
sorbitol content of liquid medications
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
decrease or discontinue narcotic meds
use low fat. low fiber formulas
administer TF at room temp
decrease the rate or volume of the feeding
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
hemodynamically unstable
fully volume resuscitated
evidence of bowel sounds is _______ required prior to the initiation of EN
NOT required
Patients at risk for refeeding syndrome should _____ delay EN
NOT delay
how should EN feeding be initiated and advanced in the hospitalized patient
use a full strength formula, start at 10-40mL/hr and advance to goal rate within 1-2 days
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
cyclic feeding
Patients who are on TF via pump and are initiated on oral foods during the day would likely benefit from ______ feedings schedules
overnight cycle feedings
what type of insulin should be used when initiating EN in a hospitalized diabetic patient?
regular insulin
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
the importance of providing adequate free water daily
What is tube feeding syndrome
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.
most enteral formulas designed for oral consumption are made up primarily of
carbohydrates (40-60% total kcals from carbs)
______ in enteral formulas designed for oral consumption provide palatability
sucrose
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
NOT
which enteral feeding method provides 240mL of formula via a syringe over as few as 4-10 minutes, 3-6 times a day
bolus
bolus feedings mimic
normal feeding schedules
what type of feeding delivery method is most appropriate for patients with a jejunostomy
continuous pump
_______ feedings via pump minimize diarrhea and abdominal bloating
continuous
which type of enteral nutrition delivery is preferred for critically ill patients
continuous
why is continuous enteral tube feeding the most appropriate for critically ill patients
controls the rate and volume
better EN tolerance
decreased aspiration risk
which of the following is a best practice recommendation in EN formula safety
change the EN feeding administration set every 24 hours with open systems
EN that is mixed, reconstituted or diluted should be done in _________ to decrease the risk of contamination
a sterile, centralized location
Only ___ to ___ hours of formula should be poured into an open set
8-12 hours
canned, ready-to-use formula hang times should be a maximum of
12 hours
closed EN formula can be safely used for ______ hours after opening
24-48 hours
__________ 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
powdered
use of purified water vs tap water does what
decreases risk of bacterial contamination
what are the benefits of closed enteral feeding systems
decreased risk of microbial contamination
minimal manipulation needed
long hang times of 24-48 hours
requires less nursing time
when transitioning from enteral to oral feeding, tube feeding may be discontinued when adequacy of oral intake meets at least _________ needs
66% of estimated needs (2/3 to 3/4)
what information should always appear on the label of an enteral feeding product given to a hospitalized patient
patient identification product name administration method route of delivery access device date and time the formula was prepared/hung/expires
when administering multiple medications via enteral feeding tubes, medications should be
administered separately and flushed with 15-30mL of water before and after administration
enteric-coated, controlled release and sustained release medications should not be ______ and given via feeding tube
crushed
what type of feeding tube requires immediate replacement if it becomes dislodged as the tract can close very quickly
jejunostomy
replacement of a jejunostomy tube requires
radiographic verification with contrast medium
the first replacement of a gastrostomy or PEG tube should be done
by the physician who inserted the tube, after that it is appropriate for trained nurses to replace them
Nasogastric or nasoduodenal tubes can be replaced by who
doctors, physicians assistances, nurse practitioner’s or appropriately trained healthcare providers
what type of formulas are most likely to occlude a feeding tube
calorie dense
high fiber
what can be done to assist with maintaining feeding tube patency in the adult patient
flush the feeding tube with 30mL of water every 4 hours during continuous feeding, and also flush after measuring GRVs
change short term feeding tubes (NG,NJ,ND)every ____ to ___ weeks
4-6 weeks
which of the following is not a research based method to restore patency to clogged feeding tubes
cranberry juice
what 3 methods are used to restore patency to clogged feeding tubes?
water flush
mechanical de-clogging devices
pancreatic enzymes mixed with NaBicarb
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
flush the feeding tube with 30mL of water after GRV assessment
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
gastric residual volumes
what methods have been proven effective in decreasing the risk of aspiration associated with enteral tube feeding in adult patients
good oral care BID
motility agents when TF intolerance
post pyloric tube when the patient is at high risk
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
switch to continuous tube feedings
recovery of gastric emptying may be slower than the return of _____ motility in the post op patient
small bowel
continuous feedings is the preferred method in the _______
small bowel
`what is the primary cause of oozing stools in a tube fed patient
fecal impaction
______ can be manifested by symptoms of diarrhea with constipation
impaction
a home enteral nutrition patient recently treated for pneumonia is noted to have new onset diarrhea. What should be the first intervention be?
obtain a CDiff culture especially if the patient was recently on abx
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?
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
Glucose in oral rehydration solutions serves what function
to promote salt and water absorption
why are commercial sports drinks not good oral rehydration solutions
they contain much more glucose and not enough sodium
what is the optimal concentration of an oral rehydration solution for patients with short bowel syndrome to promote jejunal absorption
90-120mEq/L
in critically ill patients getting early EN, which is the most likely to increase success in achieving goal feeding rates?
volume based EN feeding protocols
what is the maximum hang time for human breast milk
4 hours
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
consider adding promotility agent
