Enteral Nutrition Flashcards
1
Q
should specialty / disease specific formulas be used in the critically ill
A
no
2
Q
EN formulas containing omega three fatty acids (immune modulating) can be recommended when
A
surgical care unit
3
Q
Symptoms of GI Intolerance during EN
A
abdominal distention, increased NGT output, high GRV’s over 250mL, decreased passage of stool, increased metabolic acidosis
4
Q
If a patient has prolonged NPO status the gut will atrophy loosening the tight junctions allowing pathogens to enter the blood circulation possibly causing sepsis. Therefor what is recommended
A
start early enteral nutrition within 24-48 hours of ICU admission
5
Q
Uses for MCT Oil
A
Fat malabsorption (impaired GI tract, IBD, chylous ascites, enteropathies, pancreatitis, SBS, intestinal resection)
6
Q
What are designer triglycerides that are chemically synthesized or genetically engineered containing more EPH and DHA which are more easily absorbed
A
Structured lipids
7
Q
Where are structured lipids used in the US
A
enteral nutrition formulas
8
Q
where are structured lipids used in Europe
A
parenteral nutrition
9
Q
Function of hydrolyzed EN formulas
A
peptide based (Di and Tri peptides) , used in impaired GI function so they are more readily absorbed
10
Q
formulas with arginine should not be used when
A
severe sepsis (is the pre cursor to nitrous oxide which can cause hemodynamic instability)
11
Q
EN formulas that contain arginine, EPA, DHA and glutamine
A
immune modulating formulas
12
Q
% water in 1 kcal/mL EN formulas
A
83% water
13
Q
% water in 1.2 kcal/mL EN formulas
A
80% water
14
Q
%water in 1.5 kcal/mL EN formulas
A
76-78% water
15
Q
% water in 2 kcal/mL EN formulas
A
70-75% water
16
Q
indications for nutrition support
A
oropharyngeal dysfunction
17
Q
use of PN _____ mortality in burn patients compared to EN
A
increases
18
Q
contraindications to enteral feeding
A
intractable nausea/vomiting
high output proximal fistula
acute necrotizing pancreatitis
ileus
19
Q
Are adult TF products lactose free
A
yes
20
Q
the majority of carbohydrates in EN formulas come from
A
hydrolyzed cornstarch
21
Q
when should branch chain amino acid EN formulas be used in hepatic encephalopathy
A
when severe encephalopathy persists after trial of lactulose/neomycin
22
Q
what percentage of water do 1kcal/mL EN formulas supply
A
75-85% water
23
Q
formulas made of free amino acids are _____ formulas
A
elemental
24
Q
elemental formulas are indicated in
A
short bowel syndrome
25
enteral formulas that have intact macronutrient, require normal digestive/absorptive function
polymeric
26
isotonic EN formulas are ___ free
fiber free
27
low osmolarity (300 mOSm), fiber free, EN formula used for high risk intestinal ischemia 2/2 inadequate bowel function
isotonic formula
28
formula with small peptides, free amino acids
hydrolyzed protein EN
29
are broken down proteins/free amino acid EN formulas recommended for Chron's remission
no, intact protein formulas
30
are intact protein EN formulas okay to use in critically ill
yes
31
EN formulas recommended for patients with inadequate enzyme release, short bowel syndrome or other malabsorption syndromes
peptide based EN formulas
32
Phenylkeotnuria (PKU) is a metabolic disorder with a deficiency in the _____ enzyme
Phenylalanine Hydroxylase
33
Phenylalanine Hydroxylase coverts phenylalanine to
tyrosine
34
in PKU, this amino acid becomes essential so is added to PKU formulas
tyrosine
35
what is the primary use for enteral nutrition
providing nutrition directly to patients who cannot or are unwilling to get adequate nutrition by mouth
36
inadequate intake or expected intake for 7-14 days
| critically ill patients, working gut, hemodynamic stability are recommended for _______ nutrition
enteral
37
early nutrition in the ICU
start EN within 24-48 hours
38
when should EN be started when not on the ICU
after 7-14 days in a well nourished patient who cannot meet nutrition needs by mouth orally
39
typically, how long after PEG or PEJ placement, can EN feedings start
2 hours or per surgeon
40
short term enteral feeding is considered how long
= 4 weeks
41
long term enteral feeding is considered how long
>4 weeks
42
benefits of enteral feeding
immune function, prevents bacterial translocation, preserves gut permeability, decrease risk of infection, decrease length of stay decreases mortality
43
contraindication to EN
expected duration of use <7-10 days in nourished patient, <5-7 days in malnourished patient, short bowel syndrome (<100-150 cm bowel), severe GI bleed, severe malabsorption, distal high output fistula, intractable N/V, paralytic ileus, mechanical obstruction
44
Fermented Oligosaccharides (FOS) and inulin in En formulas help stimulate
good bacterial growth
45
if a patient has gastroparesis, consider this EN formula to help with gastric emptyin
low fiber, peptide based/hydrolyzed
46
this formula has 100% free amino acids
elemental formulas
47
in adults, elemental formulas still contain allergens true or false
true (soy and milk protein)
48
EN formula that is low in carbohydrate, high in fat and fiber
diabetic EN formula
49
are diabetic EN formulas recommended for routine use
No
50
only consider using renal formulas in AKI if
there are electrolyte abnormalities
51
are renal EN formulas recommended for routine use
no
52
renal formulas have high ____ and ___ which limits their use in post pyloric tubes
osmolarity/viscosity
53
this type of EN formula is low in carbohydrate, high in omega 6 fatty acid
pulmonary EN formula
54
this EN formula contains branched chain amino acids
hepatic EN formula
55
are EN formulas with omega 3 fatty acids recommended for routine use in ARDS/ALI
no
56
these EN formulas contain omega 3 fatty acids, glutamine, arginine, nucleotides and antixoidants
immune modulating EN formulas
57
are immune modulating EN formulas recommended for routine use in the MICU
no
58
why are immune modulating EN formulas contraindicated in septic patients
they contain arginine which is a precursor to nitrous oxide which can cause hemodynamic instability
59
when are immune modulated EN formulas recommended
surgical ICU, TBI and peri operative trauma patients, post op patients
60
types of modulars
protein (powder or liquid), carbohydrate powder, MCT oil for fat, soluble/insoluble fiber
61
these type of schedule for EN feedings can be provided by syringe, gravity or the pump
intermittent
62
type of feeding schedule where EN runs for 24 hours
continuous
63
when is a pump recommended for EN provision
jejunal feedings
64
in the critically ill what feeding method for EN is recommended
continuous
65
how should an EN feeding be started and advanced in the ICU
start 10-40ml/hr advance 10-20mL q8-12 hours until goal
66
when started on bolus feedings how should EN be started and advanced
60-120 mL per feedings then advance 60-120mL per feeding q8-12 hours
67
bolus feeding is considered this schedule type of feeding
intermittent
68
what should be written on the EN order
1. Name of the Formula
2. What type of tube will be used (PEG,PEJ etc)
3. What method of feeding (continuous, bolus)
4. What additives are needed
5. Extra safety measures (aspiration precautions)
69
what is the best method to unclog a tube feed
water flushes and prevention
70
should medications be mixed with enteral formula
no
71
can creon or zenpepare be used to unclog a feeding tube
no because they are enterically coated
72
what is the recommended enzyme for de clogging a tube feed
Viokace mixed with 324 mg of sodium bicarb or 1/8 teaspoon of baking soda mixed with 5 mL of water
73
Viokace should be mixed with _____ to remove a TF clog
324 mg sodium bicarbonate
74
Bionix
a feeding tube declogger that requires a trained professional to use. Only for gastrostomy or jejunostomy not naso or oral tubes
75
what is the definition of diarrhea
2-3 liquid stools >250 grams per day
76
high osmolarity medications or formulas, fiber, sorbitol are all possible causes of
diarrhea
77
what is recommended for fiber when a patient is having diarrhea
add or remove fiber
78
what are methods to reduce diarrhea in the enterally fed patient (in order)
1. Rule out infection
2. Reduce sorbitol containing meds (1st line)
3. Decrease TF rate
3. add or remove fiber
79
Insoluble fiber ____ transit time by adding to fecal weight
increases (makes it longer)
80
insoluble fiber works by
adding weight to stool
81
When a patient is at risk for bowel ischemia fiber should
be avoided
82
fermentable oligosacchardies that help the growth of bacteria are called
pre-biotics
83
are routine use of pre-biotics recommended
not at this time
84
what is fiber's role in constipation
can increase BM frequency when baseline BMs are low
85
ways to alleviate constipation in enterally fed patients
1. add water
2. increase physical activity
3. add fiber
4. try prune or pear juice flushes
86
Likely the main cause of nausea and vomiting in EN patients is
delayed gastric emptying
87
what can be done to help alleviate nausea/vomiting in EN patients
decrease TF rate, start pro kinetic, trial anti emetic
88
dry skin, dry mucous membranes, constipation and skin tenting, increased heart rate, decreased blood pressure are signs of ____ in EN patients,
dehydration
89
what is the best method for PEG or PEJ tube site care
clean with soap and water, keep open to air
90
is swabbing the stoma of EN the best method to test for infection
no, other normal bacteria will be there
91
what are possible signs of PEG tube site infection
fever, induration, redness, malaise
92
what is recommended standards of care for patients with EN who are at risk for aspiration
1. Elevate head of bed >30-45 degrees
2. good oral care
3. continuous feeding
4. consider post pyloric feeding
5. don't routinely check GRVs
93
how should EN formulas be stored at _______ _____
room temperature
94
once open sterile EN formulas can last ___ hours in the fridge
24 hours
95
EN bags should only be used for
24 hours
96
what is the hang time for sterile, open system EN formulas
12 hours (tetra packs)
97
If powders are added to a sterile open system feeding, how long should the hang time be decreased from 12 hours
4 hours
98
what is the hang time for powdered formulas
4 hours
99
what is the hang time for sterile closed system EN feedings
24-48 hours
100
what is the hang time for blenderized tube feeding
2 hours
101
Case: a 25 year old F with traumatic brain injury s/p MVA. She is preparing to dc to rehab and still has an NG tube. The RDN recommends transitioning to intermittent feeding to mimic real meal times. The patient develops water diarrhea on day1 of intermittent feeding. What should be done first
obtain a chest x ray to verify that the tip of the tube has not migrated to the jejunum where a large volume feeding would cause diarrhea
102
Indications for home EN feeding
motility disorder, malabsorption disorder, head/neck cancer, dysphagia, pancreatitis, obstruction, failure to thrive
103
what makes a good EN candidate
1. patient/caregiver is able to administer the EN independent of care staff
2. pt has easy access to medical care follow up
3. safe home environment
4. adequate education
104
what is involved in a safe home environment for EN
clean water, electricity, refrigeration, access to a phone, good lighting
105
what is needed to document medical necessity (by the physician)
tube type
swallow eval
gastric emptying study
fat malabsorption
106
for medicare how many days in considered permanent
90 days (3 months)
107
in order to have medicare reimbursement what conditions are covered under non functioning gut or disease of the structures that permit food reaching the small bowel)
1. non functioning gut or disease of the structures that permit food reaching the small bowel
2. Dysphagia
3. Esophageal cancer with obstruction
4. Gastroparesis
108
in order to have medicare reimbursement what conditions are covered under disease of the small bowel which impairs digestion / absorption of an oral diet
1. Small bowel disease/Chron's
| 2. SOLE source of nutrition
109
For medicare reimbursement what needs to be documented to be covered for a non standard formula
severe diarrhea trialing both fiber containing and fiber free formulas
feeding <750 kcal or >2,000 kcal/day to maintain appropriate weight
110
What is not covered under medicare for enteral nutrition
1. anorexia from mood/psych disorder
2. end stage disease
3. weight loss
4. failure to thrive
5. malnutrition in the absence of functional impairment
111
HME provider stands for
Home Medical Equipment proivder
112
which foundation provides donations to help support costs of EN
Oley foundation
113
What can food stamps be used to buy
oral supplements
114
what should be on the education checklist for EN feedings
1. how to order supplies
2. goals of HEN for the patient
3. specifics about the tubes, replacement and care
4. feeding schedule, administration, formula , water medication's
5. troubleshooting issues
6. Hangtime/storage
7. Support for home resources (Oley foundation, feeding tube awareness foundation)
115
What is the best method to assess patient's grasp of education in the home enteral nutrition session
teach back
116
when providing tube feeds by cans, you can improve success by having _____ number of cans
rounded (ex. 2 instead of 1.5)
117
after starting HEN of oftenshould follow up occur
every 3 months
118
for successful HEN, it best to have a _____ approach
multidisciplinary approach
119
DME stands for
Durable Medical Equipment company (Supplies pumps, materials and formulas)
120
A 70 year old male with dysphagia s/p stroke is now discharged home after 1 month of a rehab stay. When is the ideal time to provide HEN education
throughout the rehabilitation stay
121
this type of feeding tube is placed at skin level, good for cosmetic appearance, more comfortable for active individuals
low profile tube
122
short term feeding tubes (< 4 weeks)
nasogastric, orogastric tube
123
small bore feeding tubes are recommended for _____ while large bore/stiff tubes are recommended for _____
feeding, suction
124
Nasogastric tubes are contraindicated in
head/neck/esophageal pathology, injury preventing safe insertion
125
what is the gold standard for checking NGT placement
chest x-ray
126
how are NGTs measured before insertion
NEMU: nose to earlobe to mid umbilicus
127
Nasal Enteric Tubes tips end
the distal stomach towards the pylorous
128
In order to help place nasal enteric tubes which terminate by the pylorus of the stomach, what can aid in the placement
prokinetics, IV erythromycin 200-500 mg
129
This type of tube is placed in the nasal cavity, terminates past the ligament of Treitz
Nasojejunal tube
130
What is the most reliable method to place NJ tubes
endoscopy or fluroscopy
131
feeding tubes that are placed endoscopically require
sedation
132
How long will tube feed be needed to consider percutaneous placement
>4-6 weeks, long term
133
are testing of coagulation parameters (INR etc./ platelets) required for patients undergoing enterostomy tube placements
no; unless they are on anticoagulation medications, have excessive bleeding or on recent abx
134
patients who have had excessive bleeding, recent abx, and on anticoagulation meds may need this checked before percutaneous tube feeding placement
INR/platelets
135
patients who are at thromboembolic risk are on clopidrel/thienopyridines should have these meds held ___ to ___ days before percutaneous placement
5-7 days
136
how long should warfarin be held before PEG placement. What medication can they be bridged with in the mean time
5 days, short acting heparin
137
obstruction proximal to the GI tract, ascites, gastric varicies, active head/neck cancer, and morbid obesity are contraindications to ____ placement
PEG tube placement
138
impaired gastric motility, pancreatitis/pancreatic surgery and stomach decompression are recommended to have these types of percutaneous feeding tubes placed
PEJ
139
Fluoroscopic percutaneous tube placement must be done where
in a radiological suite
140
how long after placement can percutanous tubes be removed to ensure stoma maturity
1-2 weeks or 4-6 in extra tenuous patients
141
if PEG tubes or PEJ tubes are removed to early what are the risks
bowel contents/stomach contents can leak into the peritoneum
142
how should stomas be routinely cleaned
warm water, mild soap
143
Are routine use of antibiotics recommended for PEG tube site care
no
144
what is the best way to prevent tube feed clogging
Adequate flushing of at least 30mL of water
145
other ways of preventing tube clogging
don't check GRV's too often, avoid very concentrated formulas, don't mix meds with EN formula
146
what type of pills are more likely to promote TF clogs
crushed pills
147
medications should be given all at once or separately to prevent TF clogs
SEPERATELY with flushes in between
148
complications of NG tube placement
Epistaxis, aspiration, pneumothorax
149
reducing narcotics, low fiber/fat formulas, room temp enteral formulas, pro kinetic agent, small volume feedings and anti emetics are all solutions to this complication of tube feeding
nausea
150
abdominal distention during tube feeding can result from
ileus, obstruction, ascites, rapid formula administration of very cold formulas/high fiber
151
weight loss, steatorrhea, diarrhea, vitamin/mineral deficiencies, and glossitis could be signs/symptoms of _____ during enteral feeding
malabsroption
152
measuring fecal fat, serum citrulline, or examine intestinal transit can rule out/ identify _______of the gut
maldigestion
153
what is the most common reported GI side effect with Enteral Nutrition
diarrhea
154
medicatiosn high in sorbitol (amantadine, doxycycline, lasix, metoclopramide, isonazid and tylenol liquid meds) can cause
diarrhea
155
what items should be evaluated when a patient on enteral feeding experiences diarrhea
1. Review medications for sorbitol or pro kinetic agents
| 2. Check for bacterial causes (CDiff)
156
If medications/infectious causes of diarrhea are ruled out, what can be added to the EN regimen to reduce diarrhea
Soluble fiber and or anti diarrheal meds
157
fiber modulars have a high risk of ______ en tubes
clogging
158
what is the PRIMARY intervention to treat EN associated diarrhea
use fiber containing formula
159
what is the LAST RESORT intervention for EN associated diarrhea
switch to a peptide based formula
160
this test helps identify Small Intestinal Bacterial Overgrowth (SIBO)
hydrogen breath test
161
EN formulas are at highest risk of contamination when
they are mixed, diluted or reconstituted (powdered)
162
EN formulas that are at the lowest risk of contamination
sterile or closed systems
163
liquid formula that is provided via syringe or poured into a bag and delivered by gravity or pump is considered a _______ system
open system
164
what is the hang time of open systems (syringe, or pouring into a bag)
4-12 hours
165
this type of EN formulas is powdered or formula with added modulars provided by gravity or pump
reconstituted
166
reconstituted enteral feedings can only hang for a maximum of
4 hours
167
powdered EN formula should be mixed with _____ water
sterile
168
this type of EN formula system are contained in pre filled sterile bottles with spike or screw tops
closed system
169
closed system enteral feedings can be hung for
24-48 hours
170
what is the proper technique for preparation of formula
hand washing, gloves, aseptic technique, clean , maximum barrier precautions
171
formulas should be used _____ after opening or being reconstitution with water
immediately
172
if you have left over formula from a sterile bottle how long can it be stored in the fridge
24-48 hours
173
A sterile tube feeding formula is running at 25mL/hr for 8 hours. 200 mL of formula is left over after the feeding bag is filled where should the formula go
in the refrigerator
174
how often should TF bags be changed
every 24 hours
175
how can checking GRVs cause contamination
introducing pathogenic microorganisms when pulling back stomach contents, infecting the TF hub/port
176
Implementing Prevention Policies for EN
1. visually inspect each TF bottle for expiration date/damage
2. use proper hand washing technique, wear clean gloves
3. Prepare the formula in a clean area
4. wipe flip top bottles with isopropyl alcohol
5. Assess the TF formula for separation, thickening or curdling
6. use sterile water to prepare powdered formulas
7. Minimize frequent disconnections and reconnections of the tubes
8. keep equipment dry and clean
177
dehydration, excessive or inadequate fiber, and fluid restriction cause ________
constipation
178
if a patient is on a fluid restriction but suffering from constipation on tube feeding what can be used
stool softener
179
increasing fiber in constipation propels waste through the colon
constipation
180
Inadequate _____ can result in infrequent bowel movements and cause significant buidldup in the colon
fiber
181
firm collection of stool in the distal colon where liquid stool will seep around an impaction
obstipation
182
a rare TF complication associated with fiber modular that are formed in the stomach
bezoar
183
sings of EN Intolerance
abdominal distention, nausea, vomiting
184
dyspnea, wheezing, hypoxia, anxiety, fever, leukocytosis or new/progressing infiltrates are signs os
aspiration PNA
185
is blue dye recommended
NOOOOOOO
186
if GRV's ARE checked when should tube feeding be held
when >500 mL with vomiting or diarrhea for more than 48 hours
187
are checking GRVs routinely used to monitor ICU patients on EN
No
188
what can be used for oral care in the ICU to prevent aspiration of tube feeding
chlorhexidine
189
what populations are at risk for refeeding syndrome
malnourishment, diarrhea, high output fistula, ETOH intake, poorly controlled DM, anorexia nervosa, IBD low birth weight, prematurity
190
if an enterally fed and at risk for refeeding syndrome EN should only provide _____ of the goal on Day 1 with attention to energy contribution from ______ and advance to goal within ____ to ____ days pending elytes and clincal status
25%, 3-5 days
191
tube fed patients are at risk for ____ because EN formulas don't contain total fluid needed and require additional water flushes
dehydration
192
dry mouth, eyes and lips, light headedness when standing, headache, fatigue, heat intolerance dark urine, orthostatic hypotension, increased heart rate, poor skin turgor and sunken eyes are signs of
dehydration
193
an increased BUN:Cr ratio of 20:1 can indicate ________ when there are no renal issues
dehydration
194
typical urine output
0.5 to 2 mL/kg/hr
195
1 kg of weight = ______ liter of fluid
1
196
when a patient has a fever increase water provision by ____% per degree Celcius above 37.8 degrees
12%
197
this type of nasal feeding tube allows the most digestion as the nutrients mix with gastric juices
nasogastric
198
this type of tubing for PEGS hangs out
standard profile
199
during PEG placement, an endoscope goes down the _______, a _____ is shone through at the placement site in the stomach and the _____ is pushed through the cutaneous layer.
esophagus
light
bolster
200
what type of feeding is not recommended for jejunal feedings
bolus
201
bolus-ing tube feed into the jejunum can cause
vomiting, excessive diarrhea
202
an incorrectly positioned feeding tube, where the balloon or silicone cuff is inside the abdominal wall while the bolster is on the outside indicates
Buried Bumper Syndrome
203
pain at a PEG tube site and weight gain can indicate this complication
Buried Bumper Syndrome
204
when a tube feeding formula is accidentally connected to a ventilator or IV this considered a ____ event
sentinel
205
ENFIT was developed by this company
GEDSA Global Enteral Device Supply Association
206
ENIFT tubes prevent ________
enteral tubing misconnections
207
A patient gets an NG tube placed and is immediately started on a standard formulas of 10mL/hr. The patient develops coughing, an inability to speak and decreased O2 saturations
rule out lung placement of NG tube with a CXR
208
bleeding, peritonitis, or colo-cutaneous/colo-gastric fistulas are complications of
PEG placement
209
dislodgement of this type of tube requires immediate replacement because the tract can close quickly
dislodged jejunotomy tube
210
the dislodgement of a jejunostomy tube needs to be replaced by
a physician at the hospital as it requires radiographic verification with contrast medium to confirm placement
211
what is a common contributor to the occlusion of small bore feeding tubes
aspiration for measurement of gastric residuals
212
ways to ensure patency to avoid clogged feeding tubes
use proper TF administration
flush 15-30mL before/after each med
use digestive enzymes with sodium bicarb
use a mechaical de clogging device
213
the primary cause of diarrhea in an enterally fed patient are
medications containing sorbitol elixirs
214
a majority of enteral formulas are ___ free so patients with lactose intolerant do not have to worry about using them
lactose
215
what is the most common cause of diarrhea
bowel impaction/obstipation
216
the passage or secretion of fluid around a stool impaction that can cause loose stool/diarrhea
obstipation
217
GI mucosal edema 2/2 hypo-albuminemia may result in
severe diarrhea
218
the most common cause of diarrhea in EN formula fed patients
sorbitol containing meds/elixirs as a flavor enhancement
219
if a patient is experiencing significant diarrhea, this type of fiber can help decrease diarrhea
soluble fiber: will absorb fluid
220
An elderly nursing home resident w/ a hx of constipation with a new PEG, how can you ensure that they do not become constipatied
provide 1kcal/mL of formula with fiber and adequate water
221
an enterally fed patient suffering from constipation may benefit from additional
water/water flushes
222
causes of constipation in EN patients
dehydration, long-term fiber free feedings, prolonged bed rest, prolonged bed rest, narcotic use
223
65yo who is bed bound s/p CVA with dysphagia on 1.5 cal/mL formula at 50mL/hr, is 70 inches tall, 150 lbs and gets 60mL of water 5x/day. He develops constipation. How do you improve bowel function . What are the patient's fluid needs
1. 1mL/kcal (1800mL) or 30ml/kg (2045mL)
2. Water flushes provide 300mL total a day and the TF formula provides about900mL of water (75% H2O in 1.5 kcal formula). This is a total of 1650mL of water which is below his needs.
3. You would need to increase free water flushes for extra hydration
224
methods to help with gastroparesis in TF patients
1. discontinue narcotics (slows GI transit)
2. Try lower fat/lower fiber formula (fat/fiber slows GI emptying)
3. Administer TF at room temperature
4. administer jejunual feedings
225
what is the most likely etiology of gastric emptying in diabetics
hyperglycemia
226
enteral formulas used for diabetic gastroparesis are low in
fat and fiber and are isotonic
227
rapid bolus infusion, feeding tube migration, excessive feeding volume, gastroparesis are all possible causes of ___ in EN patients
nausea/vomiting
228
what should be done when an EN patient experiences nausea and vomiting
1. treat nausea/vomiting with regaln/zofran
| 2. decrease TF rate or volume
229
A potentially fatal condition caused by a feeding regimen given through a tube that provides too little water and too much protein in the diet is called
tube feeding syndrome
230
azotemia, hypernatremia and dehydration are symptoms or signs of
tube feeding syndrome
231
what is the etiology of tube feeding syndrome
high protein tube feeding without enough water causing a high renal solute load so nitrogen builds up in the blood stream
232
how can tube feeding syndrome be prevented
provide adequate fluid and don't use a protein load over 1.5 g/kg body weight unless warranted (burns, CRRT)
233
granulation/scar tissue can form within the feeding tube tracts and grow out onto the surface of the skin usually where
the exit site
234
how is hypergranulation around a PEG tube site prevented
1. keep PEG tube exit site dry and clean
2. Makes sure the tube is stabilized and doesn't move more than 1/4 of an inch from the stoma
3. non occlusive dressings
4. add triamcinolone cream
235
risk factors for buried bumper syndrome
weight gain especially in the abdomen
236
Increased weight gain and increased abdominal girth puts extra pressure on the bolster of a PEG tube increasing the risk for pressure necrosis and ulceration can lead to ___ ___ __
buried bumper syndrome
237
pain and pressure on the inside of the stomach, pain, bleeding, obstruction, cellulitis or abscess around the PEG site
buried bumper syndrome
238
buried bumper syndrome can be life threatening as
it can cause tube feeding formula to leak into the abdomen
239
what starting a continuous feeding start with ___ strength at ___ to __ mL/hr and gradually increase toward _____
full strength
15-20mL/hr
goal
240
why is it NOT recommended to dilute enteral formulas
can cause diarrhea or microbial contamination
reduces osmolality
decreases total calories and decreased protein
241
when chyme enters the small intestine, bile salts, pancreatic enzymes, bicarb and water are released in increasing amounts to make EN formula isotonic is called
autotonicity
242
what is the reason for early EN
to attenuate the rapid depletion of nutrient stores after metabolic stress or to maintain immune function
243
when should EN be avoided
not fully volume resuscitated
not hemodynamically stable
mesenteric profusion is not restored
244
what method of tube feeding delivery is preferred on the ICU
pump assisted
245
this type of enteral feeding methods is easy to control the rate and volume, establishes better tolerance, has fewer gastric complaints, and possibly reduces the risk for aspiration
continuous pump assisted
246
what types of feeding methods are allowed for gastric feedings
bolus, intermittent, or continuous feeding
247
this type of enteral feeding method provides 200-300mL of formula over 30-60 minutes every 4-6 hours
intermittent (gravity, bolus)
248
this method of administering enteral feedings provides EN over 8-20 hours during the day or night depending on the tolerance of the patient, allowing the patient time off the pump
cycled EN feedings
249
if a patient on a continuous EN formula will be transitioning to PO intake and EN at the same time. What can help mitigate full ness during day time feeding
cycling at night
250
if a patient is bolused into the jejunum with a PEJ or NJ what would be the consequences
diarrhea, bloating
251
when is it appropriate to start transitioning a patient from a cycled EN feeding to an oral diet
has normal GI function
not ventilated
tolerating a polymeric formula for at least 1-2 days
when EEN meets at least 60% of needs/clinical judgement
252
most enteral tubes are made out of this material
polyurethane
253
what should be performed to assess feeding tube placement prior to the initiation of enteral feeding
chest x-ray to confirm placement
254
for a post-op patient with a proximal small intestinal enterocutaneous fistula who is to be enterally fed, what is considered to be the ideal location for placement of the feeding tube in relation to the fistula site
distal to the fistula
255
before placing a PEG tube, is testing of coagulation parameters and platelets still recommended. When at all should they be tested.
1. No not recommended routinely
2. If a patient has a concern for abnormal coagulation d/t anticoagulant meds, history of excessive bleeding or recent ANTIBIOTIC USE
256
what is the most reliable method to placing nasojenunal tubes
endoscopy
| fluoroscopy
257
If a patient has recently been on antibiotics what should be checked/tested fore PEG or PEJ placement
1. INR, coagulation parameters
258
Patients on coumadin, have a high risk of bleeding or are recently on antibiotics are at high risk of PEG/PEJ placement according to
The American Society of Gastrointestinal Endoscopy Guidelines
259
clopidrel/thienopyridines (inhibits platelet aggregation) should be held ___ to ___ days before PEG/PEJ placement. If not what should be given to promote vasoconstriction in patients with high thromboembolic risk
5-7 days
| epinephrine
260
how long should warfarin be held before PEG placement
5 days
261
patients who normally take warfarin at high risk for bleeding should be bridged with short acting _______ before PEG placement
heparin
262
_____ are given prophylactically when PEG tubes are placed to decrease peristomal infection when using endoscopy
antibiotics
263
the most common method for PEG placement is
Ponsky/Pull method
264
what is the soonest a percutaneous tube can be removed after placement
1-2 weeks after the stoma has matured
265
most clinicians wait until ___to___ weeks to remove a percutaneous tube, especially for patients with immunosuppression, steroid use, obesity or poor wound healing
4-6 weeks
266
what happens when a percutaneous tube is removed too early
the stomach/bowel can fall away from the abdominal wall and bowel contents can leak into the peritoneum
267
a percutaneous tube should be replaced
endoscopically, interventional radiology or surgery
268
a standard profile or low profile percutaneous tube can be exchanged _______ unless it is a direct gastrojejunostomy or jejunostomy
at the bedside
269
if a patient suddenly develops pain, gastric leakage and reddened/ulcerated skin soon after percutaneous tube feeding placement what should be done
1. verify the placement of the tube to make sure there is no peritoneal leakage
2. Replace tube and confirm correct location with fluoroscopy or endoscopy after replacement
270
if a percutaneous feeding tube is mispositioned over time it can lead to ____ if not treated
necrotizing fasciitis
271
what is one of the best ways to prevent aspiration PNA in patients with PEG tubes/NPO
good oral hygeine
272
what is the best method to clean a percutaneous tube around the skin
warm water
mild soap
rinse and dry
273
is routine use of antibiotic ointments or hydrogen peroxide recommended to prevent infection around a stoma
No; should not be preventative
274
what are methods to prevent feeding tube clogging
1. adequate flushing with meds/feedings
2. don't over check GRV's
3. avoid high protein/high fiber formulas or use larger bore tubes
275
in order to reduce the chance of a feeding tube to clog what is essential
flushing protocol compliance
276
each patient should be evaluated in conjunction with a ___ to determine the best way to deliver a medication to a tube fed patient
Pharmacist
277
meds should be given ____ to decrease risk of clogs and be ___ before and after each administration
separately
| flushed
278
what can be used to prevent tube dislodgement
a bridle
279
cracking, breaking or kinking of a feeding tube is consider a
tube malfunction
280
obstruction of physiological sinus drainage by a naso-enteric tube is a complication of what
sinusitis
281
vomiting in minimally responsive patients may increase the risk of
aspiration PNA
282
to gastric residual volumes correlate with tube feeding tolerance
no
283
ileus, obstruction, obstipation, ascites , diarrheal illness, rapid formula admin or infusion of very cold formulas can can all cause
bloating/abd distention
284
impaired breakdown of nutrients into the absorbable forms are called
maldigestion
285
how is maldigestion tested for
fecal fat assessment
lactose tolerance test
schilling test for B12 absorption
small bowel biopsy
286
Celiac disease, Chron's disease, diverticulosis, radiation enteritis, enteric fistula, short gut and SIBO are all possible causes for
maldigestion
287
if providing a high sorbitol medication in an enteral feeding what can be provided to reduce irritation of the gut
give with at least 30-60mL of water
288
is intact protein recommended for starting patients on tube feedings
yes
289
____ might be the most tolerable form of protein in EN formulas on the critically ill patient
polypeptides
290
a patient can become ____ intolerant after illness, especially when transitioning to an oral diet because most EN formulas are ____ free. Try a ___ restricted diet to reduce diarrhea.
lactose intolerant, lactose free, lactose restricted
291
what are the first steps in managing diarrhea in an enterally tube fed patient
1. rule out infection/inflammatory causes
2. rule out fecal impaction/obstipation
3. Identify sorbitol containing medications
292
if diarrhea continues in an enterally fed patient what medication can be given to slow down the diarrhea
anti-diarrheal agent (loperamide, octreotide)
293
if a patient's abdomen (who is getting tube fed) becomes distended, tympanic or painful what should be done
1. stop the tube feed and contact the MD to evaluate
294
if diarrhea is not related to a medical or surgical reason, and has not had a BM in 5 days assess for
1. regular narcotic use, stool impaction, fluid provision
295
if a patient is not on cathartic medications, doesn't have a surgical reason and not on sorbitol medications what should be assessed with diarrhea
C Difficile
296
a patient develops 4-5 water stools a day. what should the RD evaluate.
1. is the patient getting high sorbitol or hypertonic solutions
2. are they on a pro-kinetic, antibiotic
297
To manage diarrhea in a tube fed patient (not due to medications) ____ fiber can be used in a modular or specific formula. However this can clog tubes.
soluble fiber
298
if a patient has been on prolonged antibiotics and having diarrhea, what should be tested
C Difficile
299
what is the primary EN intervention when a patient has diarrhea (not due to meds, infection, sorbitol)
use a fiber containing formula
300
what is the last resort type of formula when a patient has diarrhea (not due to meds, infection, sorbitol)
peptide based formulas
301
accumulation of excess waste in the colon is known as
constipation
302
if constipation is suspected, what should be the following steps
1. check for SBO, obstruction or ileus
303
prolonged use of ____ can cause tachyphylaxis and should not be used for constipation
sennakot
304
firm collection of stool in the distal colon where liquid stool will seep around an impaction
impaction
305
who are at risk for fecal impaction
older adults, bed bound
306
who are at risk for intestinal ischemia
neonates
critically ill
immunosuppressed
307
what precautions are used to prevent intestinal ischemia in enteral nutrition
1. delay EN until fluid resuscitated
2. avoid EN during profound hypotension/hypovolemia
3. use isotonic, fiber free EN formula
4. ongoing monitoring of abdomen, MAPs
308
what is the most invasive method of NGT placement
endoscopic, requires placement of a large instrument along with the feeding tube
309
what is used for pharmacologic stimulation of tube feeding placement
pro-kinetic to stimulate gastric peristalsis
310
the external bumper used in the placement of PEG/PEJ to hold the stomach or small bowel in place against the abdominal wall
T-fastener
311
how long are t-fasteners kept in place to allow formation of a stoma tract
10-14 days
312
air insufflation, auscultation and pH aspirates to check TF placement are not recommended as
lead to false positives and can lead to tube placement into the tracheobronchial tree
313
to decrease the risk of the feeding tube being placed into the airway during NG placement is to have the patient
bend their head forward and tuck their chin to their chest
314
the most successful way to place a trans pyloric feeding tube is
fluoroscopy
315
a 75 year old female with dementia and history of aspiration would best benefit from this tube
PEJ; decreased risk of aspiration and long term
316
contraindications to PEJ placement
end jejunostomy, short bowel syndrome if only the jejunum remains
