Enteral nutrition Flashcards
Malnutrition definition
Not meeting the metabolic demands of the body/nutrition imbalance
typically associated with weight loss (undernutrition)
but also applies to obesity (overnutrition)
populations susceptible to malnutrition
Age: elderly, infants
GI conditions (IBD, bariatric surgery, pancreatitis)
Cancer
AIDS
Developmental disabilities (CP, swallow reflex)
Hospitalized patients
How long before most patients require nutritional support (inpatient, hospitalized)
Most go 7 days before starting nutrition support
Critically ill / ICU patients can start enteral nutrition _____
earlier than the 7 days due to mortality benefit
When do outpatients require nutritional support?
patients with malnutrition or at risk of developing malnutrition
If the gut works – use it
When to use enteral vs parenteral
If the gut is functioning, use it. TPN has lots of AE
Must use gut to maintain integrity
Why do we want to maintain gut integrity?
Keeps bile flowing (bacteriostatic flow) = prevent infection
Prevents stones (cholestasis/cholelithiasis)
Immune defense: GALT, stomach acid, protective mucosal layer, peristalsis, healthy microbiota
Enteral nutrition tubes (3)
Nasal tubes (NG, ND, NJ)
Abdominal wall placement (G, J)
Nasogastric tubes
easy to place
highest aspiration risk into lung
Can push large volume
Stomach decompression possible (if intestinal block, can such material out of stomach)
Naso -jejunal/-duodenal tubes
more difficult to place
reduced aspiration risk
More likely to clog (smaller tube)
Can’t push large volume
Abdominal wall G tube
Can give larger volume bolus feeds that mimic meals (push 15min-1hr)
OK to crush and flush meds
Abdominal wall J tube
Can’t give large volumes
Must give medications as a liquid
Can’t crush/flush meds
Abdominal wall J tube
Can’t give large volumes
Must give medications as a liquid
Can’t crush/flush meds
Crushing/Flushing medications
Flush with 15-30 mL sterile water before and after
NOT FOR JEJUNAL TUBES (gastric and duodenal OK)
Do each medication separately
Do not crush SR, ER, or enteric coated
Giving liquid medications
Check osmolality
>600 mOsm = dilute with sterile water or else may cause diarrhea
If viscous - dilute or it could stick to the tubing
Enteral feeding interactions
Must stop enteral feed to give med
Medications that require feed hold 1-2 hrs before/after
Phenytoin
Fluoroquinolones abx
Levothyroxine (give IV if need adjust dose)
Warfarin (PO only)
Calculate caloric requirement for enteral nutrition
20-30 kcal/kg/day
Do patients usually require specialized enteral preps?
No, generally use standard prep
Which patients require specialized EN?
Renal/heart failure (fluid restrict)
End stage renal disease
Diabetes
Burn/trauma
Pancreatitis
Renal/HF EN adjustment
Less volume – use more concentrated formula
ESRD EN adjustment
Reduce potassium and phosphate
Diabetes EN adjustment
Calories – more fat and fiber, less sugar
Burn/trauma EN adjustment
High protein
Pancreatitis EN adjustment
low fat
Administering EN
Bolus feed (G tube)
Continuous feed (inpatient only)
Semicontinuous (overnight)
Bolus feeds calc mL
only for Gastric tubes/NG tubes
Bolus - 200mL at a time given over 15-60 min
# boluses = total volume /200mL
If you give a 200 mL NG bolus and the patient vomits, what do you do next?
Decrease volume
or
infuse over longer period of time
Continuous feeds rate
The goal rate = total mL/24 hrs
Intiate as 20ml/hr
Increase based on tolerance
Reassess every 4 hours until at goal
Calculate EN fluid requirements
1 mL/kcal/day
or
30-40 ml/kg/day
Calculate how much water to give on top of EN
Daily fluid requirement – Enteral H2O content
– daily fluid adult - 30-40ml/kg/d
Give this divided Q 4-6 hours as free water
ex: every 4 hrs (divide by 6)
Monitoring EN intolerance
Diarrhea
Bloating/distention
Electrolytes
GI wall
Nasal tube
Clogs
Diarrhea monitoring EN
> 3 liquid stools
influenced by
- feed rate (fast=D)
- osmolality (too high = D)
- lack of fiber (also helps absorb water)
- prokinetics (can cause diarrhea)
Bloating/distention monitoring EN
Use prokinetics to help
Give post pyloric (avoid gastric - ferment)
Use continuous EN – slow infusion rate
If bolus – decrease mL of bolus
Electrolyte EN monitoring
Check for hypernatremia (pt unable to sense thrist or unable to communicate)
Refeeding syndrome (rapid shift)
GI wall tube monitoring
Check exit site infections
Leaking
Bleeding
Nasal tube monitoring
Sinusitis
keep elevated to reduce risk of aspiration (30-45 deg)
Tube monitoring
Maintain patency
Flush with water before/after
Pancreatic enzymes + bicarb to clear
