Enteral and Parenteral Nutrition Flashcards
Canadian Malnutrition Task Force has adopted the following definition:
“Malnutrition includes both the deficiency or excess or imbalance of energy, protein and other nutrients”
what are the 3 broad types of malnutrition?
- Undernutrition (includes wasting)
- micronutrient-related malnutrition (includes micronutrient deficiencies)
- overweight, obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes and some cancers)
malnutrition is associated with increased risk of:
- morbidity in acute and chronic diseases
- infections
- post-op complications
- mortality
- pressure wound ulcers
- Poor wound healing
- Delayed functional - improvement
- Increased length of stay
- Increased readmission rates
- Delay in the initiation of adjunctive treatment
what percentage of patients admitted to acute care (medical and surgical wards) have moderately or severely malnourished upon admission?
42%
what percentage of people admitted to acute care have “disease-related malnutrition”?
76%
what are the 4 basic “Nursing Admission” questions that are integral to the early identification of nutritional risk patients?
(In order of importance)
- Have you lost weight?
- If Yes, How much weight have you lost and over what time frame?
- What is your current weight?
- What is your height?
what is the highest predictor of malnutrition?
weight loss of 10% in the preceding 6 months of hospital admission
In developed countries, what is the main cause of malnutrition?
disease NOT starvation
what factors of disease have the potential to result in or worsen malnutrition?
Response to trauma, infection or inflammation may alter metabolism, appetite, absorption or assimilation of nutrients
what factors are associated with poor intake in the hospital?
Organizational factors
Patient factors
what are organizational factors of poor intake in the hospital?
- Lack of nutrition awareness by healthcare providers and patients
- Inappropriate NPO status
- Multiple medical tests requiring fasted states
- Unprotected meal times (diagnostics, visitors, transfers) – staff may forget to give food to patient when meal is missed
- Adverse hospital smells and noises
- Lack of assistance at meals
- Food services issues, i.e. unpalatable food, cold food, selective options, dry and chewy food
- Lack of nutritious food options outside of meal times
what are examples of illness effects?
Poor appetite
Too sick
Tired
Pain
what are examples of eating difficulties?
- Difficulty opening packages/unwrapping food
- Uncomfortable position to eat
- Difficulty reaching food
- Difficulty chewing and swallowing food
what are the Goals of Clinical Nutrition Intervention?
- To improve clinical status and outcome
- To restore/improve nutritional status in the face of disease and injury
- To possibly modulate/attenuate the disease process
- To minimize the catastrophic effects of injury, sepsis and inflammation
- Minimize the rate of lean body mass catabolism and weight loss and work towards anabolism
- Provide essential nutrients (macro and micronutrients)
- Decrease infectious and non-infectious complications
- Reduce length of stay, costs
- Improve quality of life
what are the Clinical Nutrition Interventions to malnutrition?
- oral
- enteral nutriton (tube feeds)
- parenteral nutrition (IV, TPN)
Indications: Oral Nutrition
- Consistent with medical and patient’s goals
- Inadequate oral intake to meet nutrient needs
- Functional gastrointestinal tract (digestion and absorption)
- Safe functional swallow
what are the Indications for Enteral Nutrition?
- Consistent with medical and patient goals
- Oral intake is deemed unsafe, inadequate, or impossible to meet nutrient needs
- Functional gastrointestinal tract (digestion and absorption)
- Accessible gastrointestinal tract
what are contraindications of enteral nutrition?
- Non-operative mechanical GI obstruction
- Intractable vomiting/diarrhea
- Paralytic ileus
- Severe GI bleed
- Perforation of the GI tract
- Inability to gain access to the GI tract
- Aggressive intervention not warranted or not desired
what conditions are associated with impaired ingestion?
Intubation, facial or esophageal trauma, CVA (stroke)
what conditions are associated with inability to consume adequate nutrition?
- A condition (hyperemesis of pregnancy, anorexia associated with CHF)
- A hyper-catabolic state (Bone Marrow Transplant, severe burns, sepsis)
what conditions are associated with impaired digestion and absorption?
Pancreatic cancer, short bowel, pancreatitis, gastroparesis
what conditions are associated with severe wasting/malnutrition?
end stage liver disease awaiting transplant, severe Crohn’s disease
what are the benefits of enteral nutrition?
- Preserves GI tract integrity and function
- Reduce infectious and non-infectious complications associated with disease and injury
- Less expensive than parenteral nutrition
- Generally safer than parenteral nutrition
what are the three types of Nasoenteric feeding routes?
Nasogastric (NG), nasoduodenal (ND), nasojejunal (NJ)
are Nasogastric (NG), nasoduodenal (ND) and nasojejunal (NJ) short or long term?
short term (<3-4 weeks)
what are the 2 types of Percutaneous enterostomy?
Gastrostomy (PEG) or jejunostomy (PEJ)
are Gastrostomy (PEG) or jejunostomy (PEJ) long term or short term?
Long-term (>4 weeks)
when is Jejunal feeding indicated?
when gastric feeding is not possible or tolerated
- e.g. aspiration, gastroparesis, abdominal surgery
what are the Types of Enteral Feeding Formulas?
- standard or polymeric
- elemental or semi-elemental
- disease-specific
- immune enhancing
what are the types of standard or polymeric enteral feeding formulas?
Standard Formula
High Protein Formula
Nutrient Dense Formula
what are the types of elemental or semi-elemental enteral feeding formulas?
- Nutrients broken down for easier absorption
- Gastrointestinal impairment (e.g. gastroparesis)
- Malabsorptive conditions - pancreatitis, chemotherapy
what are the types of disease specific enteral feeding formulas?
Formulations developed for specific diseases (e.g. renal or hepatic disease, T2DM)
regarding safe enteral feeding, what does A.L.E.R.T. stand for?
- aseptic technique
- label enteral equipment
- elevate HOB
- R pt, R formula, R tube
- Trace all lines and tubing back to pt
what are some issues with enteral delivery of medications?
- Some medications require stomach acid to be activated
- Medications may interact with the formula and can’t be mixed
- Many cannot be crushed (slow release or enteric coated)
what are Potential Complications of Enteral Nutrition?
aspiration, nausea an vomiting, increasing abdominal distension, constipation an diarrhea, metabolic, tube related issues
what should happen if aspiration occurs with enteral nutrition?
Stop feed immediately
Minimize incidence: HOB > 30 degrees
what should happen if nausea/vomiting occurs with enteral nutrition?
Rate may need to be reduced or paused
Consult RD and MD
what should happen if increasing abdominal distention occurs with enteral nutrition?
Stop feeding, consult MD and assess bowel movements
what should happen if constipation/diarrhea occurs with enteral nutrition?
Consult RD and MD
Different formula and/or medications may be needed
what will happen if metabolic occurs with enteral nutrition?
Hyperglycemia
Refeeding Syndrome
what can happen if tube related issues occur with enteral nutrition?
- Blocked/clogged tube
- Leakage
- Skin infection
- Tube dislodgement
- Tube Misconnections
what are indications for parenteral nutrition?
Consistent with medical and patient goals
Patients are unable to meet nutrition needs with Enteral Nutrition
Pre-operative support in the severely malnourished patient
Gastrointestinal incompetency
what are examples of Gastrointestinal incompetency?
paralytic ileus
small or large bowel obstruction, unlikely to resolve within 5 to 7 days
severe diarrhea with evidence of malabsorption
intractable vomiting
what are contraindications of parenteral nutrition?
Functional and usable GI tract
Prognosis does not warrant aggressive nutrition support
Aggressive nutrition support is not wanted by patient or guardian
Risks judged to be greater than benefits
what is Peripheral Parenteral Nutrition?
Given through a peripheral vein
- Peripherally Inserted Central Catheter (PICC)
is Peripheral Parenteral Nutrition short term or long term?
Short term use - 7 days
what are Peripheral Parenteral Nutrition restrictions?
- Often unable to meet caloric needs
- Site rotation every 3-5 days
- Principle complication – thrombophlebitis
what is Central Parenteral Nutrition?
Infused into large central vein
- PORT
regarding nutrition intake, is peripheral parenteral nutrition or central parenteral nutrition better for caloric and protein needs?
central parenteral nutrition
how is bacterial contamination prevented in central parenteral nutrition?
Pharmacy compounds the solutions under aseptic conditions to prevent bacterial contamination
what are the two TPN routes?
peripheral parenteral nutrition and central parenteral nutrition
what are technical complications of TPN routes?
pneumothorax, hemothorax, nerve injury, subcutaneous emphysema
what are mechanical complications of TPN routes?
occlusion or fibrin sheath
thrombus
what are metabolic complications of TPN routes?
- Refeeding Syndrome
- HYPERGLYCEMIA (hypoglycemia less common, but can occur)
- electrolyte, mineral abnormalities
- hepatobiliary complications
- metabolic bone disease
what does the RD do before initiating TPN?
Nutritional Assessment
Venous access evaluation
Baseline weight
Baseline lab investigations
role of RN’s once TPN is initiated?
Monitors vital signs, temperature, ins and outs
Check blood glucose
Inspect catheter site for signs of inflammation, infection or bleeding and placement
Visually checks the solution/label (name, ID, expiry date, solution matches prescription, route of administration, leakage, emulsion stability)
Maintain aseptic techniques with all procedures related to the setup and administration of TPN and catheter care (site, flushing, hub)
Ensures that the TPN is delivered at the prescribed rate
Monitor catheters infusion ability “stiff flush”
Changes IV q 24 hrs. and with each administration of intermittent PN infusions
Discards solution if it has not been used for >4 hours
Checks drug compatibility
what is Refeeding Syndrome?
Rapid nutritional repletion in severely malnourished patients
Characterized by fluid and electrolyte disturbances: hypernatremia, hypophosphatemia, hypokalemia and hypomagnesemia
what can refeeding syndrome lead to?
fluid retention, heart and respiratory failure
what are symptoms of refeeding syndrome?
edema, cardiac arrhythmias, muscle weakness, confusion
if refeeding syndrome occurs, what should be monitored?
glucose, electrolytes, PO4 and Mg for 3 days
low serum levels must be corrected prior to TPN feeding. t or f
t
what can prevent refeeding syndrome?
Feeds are advanced slowly to prevent refeeding syndrome
weaning TPN can be based on?
oral diet/initiation of enteral feeding
when is TPN stopped in hospital?
TPN stopped when patient meeting ~50-60% of estimated requirements via EN or oral intake
when is TPN stopped at home?
Decrease total calories/day or decrease number of nights infused
