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CNSC Exam > Enteral Nutrition > Flashcards

Enteral Nutrition Flashcards

1
Q

should specialty / disease specific formulas be used in the critically ill

A

no

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2
Q

EN formulas containing omega three fatty acids (immune modulating) can be recommended when

A

surgical care unit

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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

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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

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5
Q

Uses for MCT Oil

A

Fat malabsorption (impaired GI tract, IBD, chylous ascites, enteropathies, pancreatitis, SBS, intestinal resection)

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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

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7
Q

Where are structured lipids used in the US

A

enteral nutrition formulas

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8
Q

where are structured lipids used in Europe

A

parenteral nutrition

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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

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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)

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11
Q

EN formulas that contain arginine, EPA, DHA and glutamine

A

immune modulating formulas

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12
Q

% water in 1 kcal/mL EN formulas

A

83% water

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13
Q

% water in 1.2 kcal/mL EN formulas

A

80% water

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14
Q

%water in 1.5 kcal/mL EN formulas

A

76-78% water

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15
Q

% water in 2 kcal/mL EN formulas

A

70-75% water

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16
Q

indications for nutrition support

A

oropharyngeal dysfunction

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17
Q

use of PN _____ mortality in burn patients compared to EN

A

increases

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18
Q

contraindications to enteral feeding

A

intractable nausea/vomiting
high output proximal fistula
acute necrotizing pancreatitis
ileus

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19
Q

Are adult TF products lactose free

A

yes

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20
Q

the majority of carbohydrates in EN formulas come from

A

hydrolyzed cornstarch

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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

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22
Q

what percentage of water do 1kcal/mL EN formulas supply

A

75-85% water

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23
Q

formulas made of free amino acids are _____ formulas

A

elemental

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24
Q

elemental formulas are indicated in

A

short bowel syndrome

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25
Q

enteral formulas that have intact macronutrient, require normal digestive/absorptive function

A

polymeric

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26
Q

isotonic EN formulas are ___ free

A

fiber free

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27
Q

low osmolarity (300 mOSm), fiber free, EN formula used for high risk intestinal ischemia 2/2 inadequate bowel function

A

isotonic formula

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28
Q

formula with small peptides, free amino acids

A

hydrolyzed protein EN

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29
Q

are broken down proteins/free amino acid EN formulas recommended for Chron’s remission

A

no, intact protein formulas

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30
Q

are intact protein EN formulas okay to use in critically ill

A

yes

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31
Q

EN formulas recommended for patients with inadequate enzyme release, short bowel syndrome or other malabsorption syndromes

A

peptide based EN formulas

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32
Q

Phenylkeotnuria (PKU) is a metabolic disorder with a deficiency in the _____ enzyme

A

Phenylalanine Hydroxylase

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33
Q

Phenylalanine Hydroxylase coverts phenylalanine to

A

tyrosine

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34
Q

in PKU, this amino acid becomes essential so is added to PKU formulas

A

tyrosine

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35
Q

what is the primary use for enteral nutrition

A

providing nutrition directly to patients who cannot or are unwilling to get adequate nutrition by mouth

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36
Q

inadequate intake or expected intake for 7-14 days

critically ill patients, working gut, hemodynamic stability are recommended for _______ nutrition

A

enteral

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37
Q

early nutrition in the ICU

A

start EN within 24-48 hours

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38
Q

when should EN be started when not on the ICU

A

after 7-14 days in a well nourished patient who cannot meet nutrition needs by mouth orally

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39
Q

typically, how long after PEG or PEJ placement, can EN feedings start

A

2 hours or per surgeon

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40
Q

short term enteral feeding is considered how long

A

= 4 weeks

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41
Q

long term enteral feeding is considered how long

A

> 4 weeks

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42
Q

benefits of enteral feeding

A

immune function, prevents bacterial translocation, preserves gut permeability, decrease risk of infection, decrease length of stay decreases mortality

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43
Q

contraindication to EN

A

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

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44
Q

Fermented Oligosaccharides (FOS) and inulin in En formulas help stimulate

A

good bacterial growth

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45
Q

if a patient has gastroparesis, consider this EN formula to help with gastric emptyin

A

low fiber, peptide based/hydrolyzed

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46
Q

this formula has 100% free amino acids

A

elemental formulas

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47
Q

in adults, elemental formulas still contain allergens true or false

A

true (soy and milk protein)

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48
Q

EN formula that is low in carbohydrate, high in fat and fiber

A

diabetic EN formula

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49
Q

are diabetic EN formulas recommended for routine use

A

No

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50
Q

only consider using renal formulas in AKI if

A

there are electrolyte abnormalities

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51
Q

are renal EN formulas recommended for routine use

A

no

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52
Q

renal formulas have high ____ and ___ which limits their use in post pyloric tubes

A

osmolarity/viscosity

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53
Q

this type of EN formula is low in carbohydrate, high in omega 6 fatty acid

A

pulmonary EN formula

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54
Q

this EN formula contains branched chain amino acids

A

hepatic EN formula

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55
Q

are EN formulas with omega 3 fatty acids recommended for routine use in ARDS/ALI

A

no

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56
Q

these EN formulas contain omega 3 fatty acids, glutamine, arginine, nucleotides and antixoidants

A

immune modulating EN formulas

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57
Q

are immune modulating EN formulas recommended for routine use in the MICU

A

no

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58
Q

why are immune modulating EN formulas contraindicated in septic patients

A

they contain arginine which is a precursor to nitrous oxide which can cause hemodynamic instability

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59
Q

when are immune modulated EN formulas recommended

A

surgical ICU, TBI and peri operative trauma patients, post op patients

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60
Q

types of modulars

A

protein (powder or liquid), carbohydrate powder, MCT oil for fat, soluble/insoluble fiber

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61
Q

these type of schedule for EN feedings can be provided by syringe, gravity or the pump

A

intermittent

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62
Q

type of feeding schedule where EN runs for 24 hours

A

continuous

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63
Q

when is a pump recommended for EN provision

A

jejunal feedings

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64
Q

in the critically ill what feeding method for EN is recommended

A

continuous

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65
Q

how should an EN feeding be started and advanced in the ICU

A

start 10-40ml/hr advance 10-20mL q8-12 hours until goal

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66
Q

when started on bolus feedings how should EN be started and advanced

A

60-120 mL per feedings then advance 60-120mL per feeding q8-12 hours

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67
Q

bolus feeding is considered this schedule type of feeding

A

intermittent

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68
Q

what should be written on the EN order

A
  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)
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69
Q

what is the best method to unclog a tube feed

A

water flushes and prevention

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70
Q

should medications be mixed with enteral formula

A

no

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71
Q

can creon or zenpepare be used to unclog a feeding tube

A

no because they are enterically coated

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72
Q

what is the recommended enzyme for de clogging a tube feed

A

Viokace mixed with 324 mg of sodium bicarb or 1/8 teaspoon of baking soda mixed with 5 mL of water

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73
Q

Viokace should be mixed with _____ to remove a TF clog

A

324 mg sodium bicarbonate

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74
Q

Bionix

A

a feeding tube declogger that requires a trained professional to use. Only for gastrostomy or jejunostomy not naso or oral tubes

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75
Q

what is the definition of diarrhea

A

2-3 liquid stools >250 grams per day

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76
Q

high osmolarity medications or formulas, fiber, sorbitol are all possible causes of

A

diarrhea

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77
Q

what is recommended for fiber when a patient is having diarrhea

A

add or remove fiber

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78
Q

what are methods to reduce diarrhea in the enterally fed patient (in order)

A
  1. Rule out infection
  2. Reduce sorbitol containing meds (1st line)
  3. Decrease TF rate
  4. add or remove fiber
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79
Q

Insoluble fiber ____ transit time by adding to fecal weight

A

increases (makes it longer)

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80
Q

insoluble fiber works by

A

adding weight to stool

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81
Q

When a patient is at risk for bowel ischemia fiber should

A

be avoided

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82
Q

fermentable oligosacchardies that help the growth of bacteria are called

A

pre-biotics

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83
Q

are routine use of pre-biotics recommended

A

not at this time

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84
Q

what is fiber’s role in constipation

A

can increase BM frequency when baseline BMs are low

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85
Q

ways to alleviate constipation in enterally fed patients

A
  1. add water
  2. increase physical activity
  3. add fiber
  4. try prune or pear juice flushes
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86
Q

Likely the main cause of nausea and vomiting in EN patients is

A

delayed gastric emptying

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87
Q

what can be done to help alleviate nausea/vomiting in EN patients

A

decrease TF rate, start pro kinetic, trial anti emetic

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88
Q

dry skin, dry mucous membranes, constipation and skin tenting, increased heart rate, decreased blood pressure are signs of ____ in EN patients,

A

dehydration

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89
Q

what is the best method for PEG or PEJ tube site care

A

clean with soap and water, keep open to air

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90
Q

is swabbing the stoma of EN the best method to test for infection

A

no, other normal bacteria will be there

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91
Q

what are possible signs of PEG tube site infection

A

fever, induration, redness, malaise

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92
Q

what is recommended standards of care for patients with EN who are at risk for aspiration

A
  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
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93
Q

how should EN formulas be stored at _______ _____

A

room temperature

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94
Q

once open sterile EN formulas can last ___ hours in the fridge

A

24 hours

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95
Q

EN bags should only be used for

A

24 hours

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96
Q

what is the hang time for sterile, open system EN formulas

A

12 hours (tetra packs)

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97
Q

If powders are added to a sterile open system feeding, how long should the hang time be decreased from 12 hours

A

4 hours

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98
Q

what is the hang time for powdered formulas

A

4 hours

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99
Q

what is the hang time for sterile closed system EN feedings

A

24-48 hours

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100
Q

what is the hang time for blenderized tube feeding

A

2 hours

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101
Q

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

A

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

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102
Q

Indications for home EN feeding

A

motility disorder, malabsorption disorder, head/neck cancer, dysphagia, pancreatitis, obstruction, failure to thrive

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103
Q

what makes a good EN candidate

A
  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
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104
Q

what is involved in a safe home environment for EN

A

clean water, electricity, refrigeration, access to a phone, good lighting

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105
Q

what is needed to document medical necessity (by the physician)

A

tube type
swallow eval
gastric emptying study
fat malabsorption

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106
Q

for medicare how many days in considered permanent

A

90 days (3 months)

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107
Q

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)

A
  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
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108
Q

in order to have medicare reimbursement what conditions are covered under disease of the small bowel which impairs digestion / absorption of an oral diet

A
  1. Small bowel disease/Chron’s

2. SOLE source of nutrition

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109
Q

For medicare reimbursement what needs to be documented to be covered for a non standard formula

A

severe diarrhea trialing both fiber containing and fiber free formulas

feeding <750 kcal or >2,000 kcal/day to maintain appropriate weight

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110
Q

What is not covered under medicare for enteral nutrition

A
  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
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111
Q

HME provider stands for

A

Home Medical Equipment proivder

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112
Q

which foundation provides donations to help support costs of EN

A

Oley foundation

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113
Q

What can food stamps be used to buy

A

oral supplements

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114
Q

what should be on the education checklist for EN feedings

A
  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)
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115
Q

What is the best method to assess patient’s grasp of education in the home enteral nutrition session

A

teach back

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116
Q

when providing tube feeds by cans, you can improve success by having _____ number of cans

A

rounded (ex. 2 instead of 1.5)

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117
Q

after starting HEN of oftenshould follow up occur

A

every 3 months

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118
Q

for successful HEN, it best to have a _____ approach

A

multidisciplinary approach

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119
Q

DME stands for

A

Durable Medical Equipment company (Supplies pumps, materials and formulas)

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120
Q

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

A

throughout the rehabilitation stay

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121
Q

this type of feeding tube is placed at skin level, good for cosmetic appearance, more comfortable for active individuals

A

low profile tube

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122
Q

short term feeding tubes (< 4 weeks)

A

nasogastric, orogastric tube

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123
Q

small bore feeding tubes are recommended for _____ while large bore/stiff tubes are recommended for _____

A

feeding, suction

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124
Q

Nasogastric tubes are contraindicated in

A

head/neck/esophageal pathology, injury preventing safe insertion

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125
Q

what is the gold standard for checking NGT placement

A

chest x-ray

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126
Q

how are NGTs measured before insertion

A

NEMU: nose to earlobe to mid umbilicus

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127
Q

Nasal Enteric Tubes tips end

A

the distal stomach towards the pylorous

128
Q

In order to help place nasal enteric tubes which terminate by the pylorus of the stomach, what can aid in the placement

A

prokinetics, IV erythromycin 200-500 mg

129
Q

This type of tube is placed in the nasal cavity, terminates past the ligament of Treitz

A

Nasojejunal tube

130
Q

What is the most reliable method to place NJ tubes

A

endoscopy or fluroscopy

131
Q

feeding tubes that are placed endoscopically require

A

sedation

132
Q

How long will tube feed be needed to consider percutaneous placement

A

> 4-6 weeks, long term

133
Q

are testing of coagulation parameters (INR etc./ platelets) required for patients undergoing enterostomy tube placements

A

no; unless they are on anticoagulation medications, have excessive bleeding or on recent abx

134
Q

patients who have had excessive bleeding, recent abx, and on anticoagulation meds may need this checked before percutaneous tube feeding placement

A

INR/platelets

135
Q

patients who are at thromboembolic risk are on clopidrel/thienopyridines should have these meds held ___ to ___ days before percutaneous placement

A

5-7 days

136
Q

how long should warfarin be held before PEG placement. What medication can they be bridged with in the mean time

A

5 days, short acting heparin

137
Q

obstruction proximal to the GI tract, ascites, gastric varicies, active head/neck cancer, and morbid obesity are contraindications to ____ placement

A

PEG tube placement

138
Q

impaired gastric motility, pancreatitis/pancreatic surgery and stomach decompression are recommended to have these types of percutaneous feeding tubes placed

A

PEJ

139
Q

Fluoroscopic percutaneous tube placement must be done where

A

in a radiological suite

140
Q

how long after placement can percutanous tubes be removed to ensure stoma maturity

A

1-2 weeks or 4-6 in extra tenuous patients

141
Q

if PEG tubes or PEJ tubes are removed to early what are the risks

A

bowel contents/stomach contents can leak into the peritoneum

142
Q

how should stomas be routinely cleaned

A

warm water, mild soap

143
Q

Are routine use of antibiotics recommended for PEG tube site care

A

no

144
Q

what is the best way to prevent tube feed clogging

A

Adequate flushing of at least 30mL of water

145
Q

other ways of preventing tube clogging

A

don’t check GRV’s too often, avoid very concentrated formulas, don’t mix meds with EN formula

146
Q

what type of pills are more likely to promote TF clogs

A

crushed pills

147
Q

medications should be given all at once or separately to prevent TF clogs

A

SEPERATELY with flushes in between

148
Q

complications of NG tube placement

A

Epistaxis, aspiration, pneumothorax

149
Q

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

A

nausea

150
Q

abdominal distention during tube feeding can result from

A

ileus, obstruction, ascites, rapid formula administration of very cold formulas/high fiber

151
Q

weight loss, steatorrhea, diarrhea, vitamin/mineral deficiencies, and glossitis could be signs/symptoms of _____ during enteral feeding

A

malabsroption

152
Q

measuring fecal fat, serum citrulline, or examine intestinal transit can rule out/ identify _______of the gut

A

maldigestion

153
Q

what is the most common reported GI side effect with Enteral Nutrition

A

diarrhea

154
Q

medicatiosn high in sorbitol (amantadine, doxycycline, lasix, metoclopramide, isonazid and tylenol liquid meds) can cause

A

diarrhea

155
Q

what items should be evaluated when a patient on enteral feeding experiences diarrhea

A
  1. Review medications for sorbitol or pro kinetic agents

2. Check for bacterial causes (CDiff)

156
Q

If medications/infectious causes of diarrhea are ruled out, what can be added to the EN regimen to reduce diarrhea

A

Soluble fiber and or anti diarrheal meds

157
Q

fiber modulars have a high risk of ______ en tubes

A

clogging

158
Q

what is the PRIMARY intervention to treat EN associated diarrhea

A

use fiber containing formula

159
Q

what is the LAST RESORT intervention for EN associated diarrhea

A

switch to a peptide based formula

160
Q

this test helps identify Small Intestinal Bacterial Overgrowth (SIBO)

A

hydrogen breath test

161
Q

EN formulas are at highest risk of contamination when

A

they are mixed, diluted or reconstituted (powdered)

162
Q

EN formulas that are at the lowest risk of contamination

A

sterile or closed systems

163
Q

liquid formula that is provided via syringe or poured into a bag and delivered by gravity or pump is considered a _______ system

A

open system

164
Q

what is the hang time of open systems (syringe, or pouring into a bag)

A

4-12 hours

165
Q

this type of EN formulas is powdered or formula with added modulars provided by gravity or pump

A

reconstituted

166
Q

reconstituted enteral feedings can only hang for a maximum of

A

4 hours

167
Q

powdered EN formula should be mixed with _____ water

A

sterile

168
Q

this type of EN formula system are contained in pre filled sterile bottles with spike or screw tops

A

closed system

169
Q

closed system enteral feedings can be hung for

A

24-48 hours

170
Q

what is the proper technique for preparation of formula

A

hand washing, gloves, aseptic technique, clean , maximum barrier precautions

171
Q

formulas should be used _____ after opening or being reconstitution with water

A

immediately

172
Q

if you have left over formula from a sterile bottle how long can it be stored in the fridge

A

24-48 hours

173
Q

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

A

in the refrigerator

174
Q

how often should TF bags be changed

A

every 24 hours

175
Q

how can checking GRVs cause contamination

A

introducing pathogenic microorganisms when pulling back stomach contents, infecting the TF hub/port

176
Q

Implementing Prevention Policies for EN

A
  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
Q

dehydration, excessive or inadequate fiber, and fluid restriction cause ________

A

constipation

178
Q

if a patient is on a fluid restriction but suffering from constipation on tube feeding what can be used

A

stool softener

179
Q

increasing fiber in constipation propels waste through the colon

A

constipation

180
Q

Inadequate _____ can result in infrequent bowel movements and cause significant buidldup in the colon

A

fiber

181
Q

firm collection of stool in the distal colon where liquid stool will seep around an impaction

A

obstipation

182
Q

a rare TF complication associated with fiber modular that are formed in the stomach

A

bezoar

183
Q

sings of EN Intolerance

A

abdominal distention, nausea, vomiting

184
Q

dyspnea, wheezing, hypoxia, anxiety, fever, leukocytosis or new/progressing infiltrates are signs os

A

aspiration PNA

185
Q

is blue dye recommended

A

NOOOOOOO

186
Q

if GRV’s ARE checked when should tube feeding be held

A

when >500 mL with vomiting or diarrhea for more than 48 hours

187
Q

are checking GRVs routinely used to monitor ICU patients on EN

A

No

188
Q

what can be used for oral care in the ICU to prevent aspiration of tube feeding

A

chlorhexidine

189
Q

what populations are at risk for refeeding syndrome

A

malnourishment, diarrhea, high output fistula, ETOH intake, poorly controlled DM, anorexia nervosa, IBD low birth weight, prematurity

190
Q

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

A

25%, 3-5 days

191
Q

tube fed patients are at risk for ____ because EN formulas don’t contain total fluid needed and require additional water flushes

A

dehydration

192
Q

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

A

dehydration

193
Q

an increased BUN:Cr ratio of 20:1 can indicate ________ when there are no renal issues

A

dehydration

194
Q

typical urine output

A

0.5 to 2 mL/kg/hr

195
Q

1 kg of weight = ______ liter of fluid

A

1

196
Q

when a patient has a fever increase water provision by ____% per degree Celcius above 37.8 degrees

A

12%

197
Q

this type of nasal feeding tube allows the most digestion as the nutrients mix with gastric juices

A

nasogastric

198
Q

this type of tubing for PEGS hangs out

A

standard profile

199
Q

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.

A

esophagus
light
bolster

200
Q

what type of feeding is not recommended for jejunal feedings

A

bolus

201
Q

bolus-ing tube feed into the jejunum can cause

A

vomiting, excessive diarrhea

202
Q

an incorrectly positioned feeding tube, where the balloon or silicone cuff is inside the abdominal wall while the bolster is on the outside indicates

A

Buried Bumper Syndrome

203
Q

pain at a PEG tube site and weight gain can indicate this complication

A

Buried Bumper Syndrome

204
Q

when a tube feeding formula is accidentally connected to a ventilator or IV this considered a ____ event

A

sentinel

205
Q

ENFIT was developed by this company

A

GEDSA Global Enteral Device Supply Association

206
Q

ENIFT tubes prevent ________

A

enteral tubing misconnections

207
Q

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

A

rule out lung placement of NG tube with a CXR

208
Q

bleeding, peritonitis, or colo-cutaneous/colo-gastric fistulas are complications of

A

PEG placement

209
Q

dislodgement of this type of tube requires immediate replacement because the tract can close quickly

A

dislodged jejunotomy tube

210
Q

the dislodgement of a jejunostomy tube needs to be replaced by

A

a physician at the hospital as it requires radiographic verification with contrast medium to confirm placement

211
Q

what is a common contributor to the occlusion of small bore feeding tubes

A

aspiration for measurement of gastric residuals

212
Q

ways to ensure patency to avoid clogged feeding tubes

A

use proper TF administration
flush 15-30mL before/after each med
use digestive enzymes with sodium bicarb
use a mechaical de clogging device

213
Q

the primary cause of diarrhea in an enterally fed patient are

A

medications containing sorbitol elixirs

214
Q

a majority of enteral formulas are ___ free so patients with lactose intolerant do not have to worry about using them

A

lactose

215
Q

what is the most common cause of diarrhea

A

bowel impaction/obstipation

216
Q

the passage or secretion of fluid around a stool impaction that can cause loose stool/diarrhea

A

obstipation

217
Q

GI mucosal edema 2/2 hypo-albuminemia may result in

A

severe diarrhea

218
Q

the most common cause of diarrhea in EN formula fed patients

A

sorbitol containing meds/elixirs as a flavor enhancement

219
Q

if a patient is experiencing significant diarrhea, this type of fiber can help decrease diarrhea

A

soluble fiber: will absorb fluid

220
Q

An elderly nursing home resident w/ a hx of constipation with a new PEG, how can you ensure that they do not become constipatied

A

provide 1kcal/mL of formula with fiber and adequate water

221
Q

an enterally fed patient suffering from constipation may benefit from additional

A

water/water flushes

222
Q

causes of constipation in EN patients

A

dehydration, long-term fiber free feedings, prolonged bed rest, prolonged bed rest, narcotic use

223
Q

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

A
  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
Q

methods to help with gastroparesis in TF patients

A
  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
Q

what is the most likely etiology of gastric emptying in diabetics

A

hyperglycemia

226
Q

enteral formulas used for diabetic gastroparesis are low in

A

fat and fiber and are isotonic

227
Q

rapid bolus infusion, feeding tube migration, excessive feeding volume, gastroparesis are all possible causes of ___ in EN patients

A

nausea/vomiting

228
Q

what should be done when an EN patient experiences nausea and vomiting

A
  1. treat nausea/vomiting with regaln/zofran

2. decrease TF rate or volume

229
Q

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

A

tube feeding syndrome

230
Q

azotemia, hypernatremia and dehydration are symptoms or signs of

A

tube feeding syndrome

231
Q

what is the etiology of tube feeding syndrome

A

high protein tube feeding without enough water causing a high renal solute load so nitrogen builds up in the blood stream

232
Q

how can tube feeding syndrome be prevented

A

provide adequate fluid and don’t use a protein load over 1.5 g/kg body weight unless warranted (burns, CRRT)

233
Q

granulation/scar tissue can form within the feeding tube tracts and grow out onto the surface of the skin usually where

A

the exit site

234
Q

how is hypergranulation around a PEG tube site prevented

A
  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
Q

risk factors for buried bumper syndrome

A

weight gain especially in the abdomen

236
Q

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 ___ ___ __

A

buried bumper syndrome

237
Q

pain and pressure on the inside of the stomach, pain, bleeding, obstruction, cellulitis or abscess around the PEG site

A

buried bumper syndrome

238
Q

buried bumper syndrome can be life threatening as

A

it can cause tube feeding formula to leak into the abdomen

239
Q

what starting a continuous feeding start with ___ strength at ___ to __ mL/hr and gradually increase toward _____

A

full strength
15-20mL/hr
goal

240
Q

why is it NOT recommended to dilute enteral formulas

A

can cause diarrhea or microbial contamination
reduces osmolality
decreases total calories and decreased protein

241
Q

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

A

autotonicity

242
Q

what is the reason for early EN

A

to attenuate the rapid depletion of nutrient stores after metabolic stress or to maintain immune function

243
Q

when should EN be avoided

A

not fully volume resuscitated
not hemodynamically stable
mesenteric profusion is not restored

244
Q

what method of tube feeding delivery is preferred on the ICU

A

pump assisted

245
Q

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

A

continuous pump assisted

246
Q

what types of feeding methods are allowed for gastric feedings

A

bolus, intermittent, or continuous feeding

247
Q

this type of enteral feeding method provides 200-300mL of formula over 30-60 minutes every 4-6 hours

A

intermittent (gravity, bolus)

248
Q

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

A

cycled EN feedings

249
Q

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

A

cycling at night

250
Q

if a patient is bolused into the jejunum with a PEJ or NJ what would be the consequences

A

diarrhea, bloating

251
Q

when is it appropriate to start transitioning a patient from a cycled EN feeding to an oral diet

A

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
Q

most enteral tubes are made out of this material

A

polyurethane

253
Q

what should be performed to assess feeding tube placement prior to the initiation of enteral feeding

A

chest x-ray to confirm placement

254
Q

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

A

distal to the fistula

255
Q

before placing a PEG tube, is testing of coagulation parameters and platelets still recommended. When at all should they be tested.

A
  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
Q

what is the most reliable method to placing nasojenunal tubes

A

endoscopy

fluoroscopy

257
Q

If a patient has recently been on antibiotics what should be checked/tested fore PEG or PEJ placement

A
  1. INR, coagulation parameters
258
Q

Patients on coumadin, have a high risk of bleeding or are recently on antibiotics are at high risk of PEG/PEJ placement according to

A

The American Society of Gastrointestinal Endoscopy Guidelines

259
Q

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

A

5-7 days

epinephrine

260
Q

how long should warfarin be held before PEG placement

A

5 days

261
Q

patients who normally take warfarin at high risk for bleeding should be bridged with short acting _______ before PEG placement

A

heparin

262
Q

_____ are given prophylactically when PEG tubes are placed to decrease peristomal infection when using endoscopy

A

antibiotics

263
Q

the most common method for PEG placement is

A

Ponsky/Pull method

264
Q

what is the soonest a percutaneous tube can be removed after placement

A

1-2 weeks after the stoma has matured

265
Q

most clinicians wait until ___to___ weeks to remove a percutaneous tube, especially for patients with immunosuppression, steroid use, obesity or poor wound healing

A

4-6 weeks

266
Q

what happens when a percutaneous tube is removed too early

A

the stomach/bowel can fall away from the abdominal wall and bowel contents can leak into the peritoneum

267
Q

a percutaneous tube should be replaced

A

endoscopically, interventional radiology or surgery

268
Q

a standard profile or low profile percutaneous tube can be exchanged _______ unless it is a direct gastrojejunostomy or jejunostomy

A

at the bedside

269
Q

if a patient suddenly develops pain, gastric leakage and reddened/ulcerated skin soon after percutaneous tube feeding placement what should be done

A
  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
Q

if a percutaneous feeding tube is mispositioned over time it can lead to ____ if not treated

A

necrotizing fasciitis

271
Q

what is one of the best ways to prevent aspiration PNA in patients with PEG tubes/NPO

A

good oral hygeine

272
Q

what is the best method to clean a percutaneous tube around the skin

A

warm water
mild soap
rinse and dry

273
Q

is routine use of antibiotic ointments or hydrogen peroxide recommended to prevent infection around a stoma

A

No; should not be preventative

274
Q

what are methods to prevent feeding tube clogging

A
  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
Q

in order to reduce the chance of a feeding tube to clog what is essential

A

flushing protocol compliance

276
Q

each patient should be evaluated in conjunction with a ___ to determine the best way to deliver a medication to a tube fed patient

A

Pharmacist

277
Q

meds should be given ____ to decrease risk of clogs and be ___ before and after each administration

A

separately

flushed

278
Q

what can be used to prevent tube dislodgement

A

a bridle

279
Q

cracking, breaking or kinking of a feeding tube is consider a

A

tube malfunction

280
Q

obstruction of physiological sinus drainage by a naso-enteric tube is a complication of what

A

sinusitis

281
Q

vomiting in minimally responsive patients may increase the risk of

A

aspiration PNA

282
Q

to gastric residual volumes correlate with tube feeding tolerance

A

no

283
Q

ileus, obstruction, obstipation, ascites , diarrheal illness, rapid formula admin or infusion of very cold formulas can can all cause

A

bloating/abd distention

284
Q

impaired breakdown of nutrients into the absorbable forms are called

A

maldigestion

285
Q

how is maldigestion tested for

A

fecal fat assessment
lactose tolerance test
schilling test for B12 absorption
small bowel biopsy

286
Q

Celiac disease, Chron’s disease, diverticulosis, radiation enteritis, enteric fistula, short gut and SIBO are all possible causes for

A

maldigestion

287
Q

if providing a high sorbitol medication in an enteral feeding what can be provided to reduce irritation of the gut

A

give with at least 30-60mL of water

288
Q

is intact protein recommended for starting patients on tube feedings

A

yes

289
Q

____ might be the most tolerable form of protein in EN formulas on the critically ill patient

A

polypeptides

290
Q

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.

A

lactose intolerant, lactose free, lactose restricted

291
Q

what are the first steps in managing diarrhea in an enterally tube fed patient

A
  1. rule out infection/inflammatory causes
  2. rule out fecal impaction/obstipation
  3. Identify sorbitol containing medications
292
Q

if diarrhea continues in an enterally fed patient what medication can be given to slow down the diarrhea

A

anti-diarrheal agent (loperamide, octreotide)

293
Q

if a patient’s abdomen (who is getting tube fed) becomes distended, tympanic or painful what should be done

A
  1. stop the tube feed and contact the MD to evaluate
294
Q

if diarrhea is not related to a medical or surgical reason, and has not had a BM in 5 days assess for

A
  1. regular narcotic use, stool impaction, fluid provision
295
Q

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

A

C Difficile

296
Q

a patient develops 4-5 water stools a day. what should the RD evaluate.

A
  1. is the patient getting high sorbitol or hypertonic solutions
  2. are they on a pro-kinetic, antibiotic
297
Q

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.

A

soluble fiber

298
Q

if a patient has been on prolonged antibiotics and having diarrhea, what should be tested

A

C Difficile

299
Q

what is the primary EN intervention when a patient has diarrhea (not due to meds, infection, sorbitol)

A

use a fiber containing formula

300
Q

what is the last resort type of formula when a patient has diarrhea (not due to meds, infection, sorbitol)

A

peptide based formulas

301
Q

accumulation of excess waste in the colon is known as

A

constipation

302
Q

if constipation is suspected, what should be the following steps

A
  1. check for SBO, obstruction or ileus
303
Q

prolonged use of ____ can cause tachyphylaxis and should not be used for constipation

A

sennakot

304
Q

firm collection of stool in the distal colon where liquid stool will seep around an impaction

A

impaction

305
Q

who are at risk for fecal impaction

A

older adults, bed bound

306
Q

who are at risk for intestinal ischemia

A

neonates
critically ill
immunosuppressed

307
Q

what precautions are used to prevent intestinal ischemia in enteral nutrition

A
  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
Q

what is the most invasive method of NGT placement

A

endoscopic, requires placement of a large instrument along with the feeding tube

309
Q

what is used for pharmacologic stimulation of tube feeding placement

A

pro-kinetic to stimulate gastric peristalsis

310
Q

the external bumper used in the placement of PEG/PEJ to hold the stomach or small bowel in place against the abdominal wall

A

T-fastener

311
Q

how long are t-fasteners kept in place to allow formation of a stoma tract

A

10-14 days

312
Q

air insufflation, auscultation and pH aspirates to check TF placement are not recommended as

A

lead to false positives and can lead to tube placement into the tracheobronchial tree

313
Q

to decrease the risk of the feeding tube being placed into the airway during NG placement is to have the patient

A

bend their head forward and tuck their chin to their chest

314
Q

the most successful way to place a trans pyloric feeding tube is

A

fluoroscopy

315
Q

a 75 year old female with dementia and history of aspiration would best benefit from this tube

A

PEJ; decreased risk of aspiration and long term

316
Q

contraindications to PEJ placement

A

end jejunostomy, short bowel syndrome if only the jejunum remains

CNSC Exam (32 decks)

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