Enteral Nutrition Administration, Monitoring and Clinical Issues Flashcards
1
Q
What was blue dye previously used for in regards to enteral tube feeding?
A
The addition of blue dye to enteral feedings was common practice in the past to help detect aspiration of formula.
2
Q
Why is blue dye no longer used in detecting aspiration of tube feed formula?
A
Several cases of systemic toxicity, some resulting in death, have been reported.
As a result the U.S. Food and Drug Administration removed FD&C Blue #1 from the market in 2003.
3
Q
What alternatives are available to FD&C Blue #1
A
Other blue dyes such as methylene blue and FD&C Blue #2 may have similar or greater toxicity than Blue #1 and are not suitable alternatives
4
Q
Name 4 interventions that may improve gastric emptying and reduce the symptoms of nausea and vomiting in tube fed patients
A
- Reduction or discontinuation of narcotic meds
- Use of low fat formulas
- Administering enteral formula at room temperature
- Reducing the rate and/or volume of tube feeding infusion
5
Q
Why are concentrated enteral solutions harder to tolerate?
A
Concentrated enteral solutions generally contain more fat and can further contribute to enteral intolerance by presenting a higher osmotic load to the GI tract.
6
Q
What may cause constipation in an enterally fed patient?
A
- Lack of adequate hydration
- Long-term fiber-free feedings
- Prolonged bedrest
- Impaction
- Obstruction
- Narcotics.
7
Q
The EN formula label should reflect the elements of the EN order form and therefore contain the following 5 things:
A
- Patient identifiers
- Product name
- Enteral access delivery site
- Administration method
- Time/date the formula was prepared and hung
8
Q
Name three infectious etiologies of diarrhea in tube fed patients?
A
- Bacterial contamination of enteral tube feeding formula or equipment
- Clostridium difficile
9
Q
Should a tube-fed patient with diarrhea be trialed on an elemental formula?
A
There is no need to change to an elemental formula if there are no other indications for an elemental diet
10
Q
Where should enteral formulas be mixed, reconstituted, or diluted to minimize the risk of contamination?
A
In a sterile centralized location, such as an enteral formulary room or pharmacy
This practice helps maintain safety standards for enteral feeding.
11
Q
How often should the feeding administration set be changed?
A
Every 24 hours
Disposable feeding administration sets should not be reused.
12
Q
How often should administration sets for human breast milk be changed?
A
Every 4 hours
This is a specific exception to the standard 24-hour change rule.
13
Q
What is the maximum hang time for canned, ready-to-use formulas?
A
No longer than 12 hours
This guideline ensures the safety and quality of the formula.
14
Q
For how long can closed-system EN formulas be safely used after opening?
A
24-48 hours, depending on manufacturer’s guidelines
This varies based on specific product instructions.
15
Q
Powdered formulas reconstituted in advance should be discarded after ___ without use.
A
24 hours
Powdered formulas must be refrigerated immediately after preparation.
16
Q
How long should reconstituted powdered formulas be exposed to room temperature?
A
Should be refrigerated immediately. They should be at room temp for no longer than 4 hours
This minimizes the risk of bacterial growth.
17
Q
What type of water should be used in formula reconstitution to minimize contamination?
A
Purified water
This reduces the potential risks associated with tap water.
18
Q
Can you add fresh formula to a formula system that is already hanging?
A
No. Adding fresh formula to formula already hanging in the administration set should be avoided.
This can lead to contamination.
19
Q
What hygiene practices should be followed before touching any component of the tube feeding system?
A
Hands should be washed thoroughly and gloved
This is essential to prevent contamination.
20
Q
What type of NGT placement device shows a real-time perspective of the tube tip location with a 3-dimensional localization?
A
Describe electromagnetic placement device for nasogastric tube placement
21
Q
Electromagnetic placement devices have a receiver that is placed on the patient at the ___ ___, therefore the magnet follows the tip placement relative to the lower ___ sphincter, not the ___.
A
-Xiphoid process
-Lower esophageal sphincter
-Not the pylorus.
22
Q
What is tube feeding syndrome?
A
Related to the use of high-protein tube feedings without adequate fluid provision.
23
Q
What are the risks of inadequate fluid delivery in tube fed patients?
A
Results in an inability to sufficiently excrete the solute load which can lead to the development of azotemia, hypernatremia, and dehydration.
24
Q
Prevention and treatment of tube feeding syndrome requires the provisions of adequate fluid (___-___ml/kg/day meets fluid requirements for the average adult).
A
30-40
25
What component of the tube feed regimen may need to be adjusted if the patient is unable to excrete byproducts of protein - even when provided adequate fluid?
A reduction in protein may be necessary
26
Why would cranberry juice and carbonated beverages be inappropriate to treat a tube feed occlusion?
May worsen occlusions because of the acidic pH of these fluids.
Acid can cause proteins in enteral formulae to precipitate within the tube, making the clog worse or leading to more clogging later on.
27
What is the first line of treatment for a tube feed occlusion?
Water is the fluid of choice.
28
What are second line treatments of treating a tube feed occlusion?
If water does not work, a pancreatic enzyme solution, an enzymatic declogging kit, or mechanical devices for clearing feeding tubes are second-line options.
29
What are the 2 major benefits of initiating tube feeds with a full strength formula?
1. Allows goal rates to be achieved earlier
2. Reduces the risk for microbial contamination by minimizing the number of times the formulas is manipulated
30
What type of tube feed regimen would facilitate more steady and predictable blood glucose concentrations in critically ill patients?
Continuous infusions of enteral feeding
31
What type of insulin regimen would facilitate more steady and predictable blood glucose concentrations in critically ill patients?
Continuous infusions of insulin
32
Why might intermittent, cyclic, or bolus feeding schedules be inappropriate in a critically ill patient?
May cause fluctuations in blood glucose concentrations, placing patients at risk for hypoglycemic and hyperglycemic complications
33
What should be considered before converting intravenous medications to the enteral route?
Factors that dictate appropriateness include:
-tube size
- tube tip location
- site of medication absorption
## Footnote
These factors ensure safe and effective medication administration via enteral feeding tubes.
34
What is the recommended flushing volume before, between, and after administering medications through an enteral feeding tube?
At least 15-30 mL of water
## Footnote
Flushing helps maintain tube patency and ensures proper medication delivery.
35
True or False: It is safe to mix two or more drugs together before administering them through an enteral feeding tube.
False
## Footnote
Mixing can lead to drug-drug interactions and may compromise the effectiveness of the medications.
36
What types of medications should not be crushed for administration through an enteral feeding tube?
Medications that should not be crushed include:
- enteric-coated medications
- controlled-release medications
- sustained release medications
## Footnote
Crushing these types can alter their intended release and absorption characteristics.
37
Volume-based EN feeding protocols prescribe EN in terms of the goal per ___ vs. goal per ___
EN in terms of the goal per day vs. goal per hour
38
What are the names of two protocols that improve nutrient delivery?
- FEED ME (FeedEarly Enteral Diet Adequately for Maximum Effect)
- PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol)
39
What is a potential drawback of small bowel feeding?
While small bowel feeding is superior to gastric feeding in terms of nutrient delivery, it can be interrupted during the day and is therefore likely not as effective as volume-based protocols.
40
What type of feeding tube requires immediate replacement and why?
The jejunostomy tube requires immediate replacement since the tract for the jejunostomy tube can close quickly.
41
What is required for to confirm the replacement of a jejunostomy tube?
Radiographic verification with contrast medium
42
Who can replace a PEG tube?
The first replacement of a gastrostomy or percutaneous endoscopic gastrostomy tube should be performed by the physician who inserted the tube. After that, it is appropriate for trained nurses to replace these tubes.
43
Who can place a nasal gastric or nasoduodenal tube?
A nasogastric or nasoduodenal tube can be replaced by a physician, physician assistant, nurse practitioner, or appropriately trained healthcare provider.
44
What are the 2 ways bacterial contamination occur in tube fed patients?
Bacterial contamination may occur both exogenously through the feeding equipment and endogenously through retrograde contamination of the feeding apparatus from the patient's own infected secretions.
45
True or false: There is a correlation between prolonged length of enteral product hang time and bacterial contamination.
True
46
___ systems provide more opportunity for contamination due to nursing manipulation when adding more formula to the bag.
Open
47
Is there sorbitol in enteral tube feed products?
Sorbitol is not an ingredient of enteral products however the cumulative daily dose of sorbitol from liquid medications can easily equal purgative dosages.
48
As little as ___ to ___ g of sorbitol can lead to GI side effects, including diarrhea.
10-20
49
___ insulin may minimize the incidence of hypoglycemia when initiating enteral nutrition as tolerance and titration of enteral delivery may be unpredictable.
Regular
50
Regular insulin is ___ acting
Short acting
51
During tube feed initiation, longer acting insulins could increase the incidence of ___ due to longer duration of action in the setting of feeding discontinuation or reduction.
Hypoglycemia
52
Premixed NPH/regular insulin and NPH insulin are ___ acting
Intermediate acting
53
Glargine insulin is ___ acting
Long acting
54
Once enteral nutrition administration is stable, use of a ___ insulin regimen is recommended to achieve safe, effective glucose control.
Basal/bolus
55
Cyclic feedings are generally administered over ___ to ___ hours.
8-20 hours
56
True or false: Patients who are hemodynamically unstable should not receive tube feeding until they are fully resuscitated.
True
57
Critically ill patients with labile blood glucose levels are more likely to require ___ feeding to prevent episodes of extreme hypo- or hyperglycemia.
Continuous
58
During times of shortages, who should tube feeding pumps first be allocated to?
During times of shortages, tube feeding pumps should first be allocated to patients receiving small bowel tube feeding or who have demonstrated intolerance to gravity or bolus feeding.
59
What is hypergranulation in regard to a PEG tube?
Granulation tissue is normal and often forms within the tract and may grow out onto the surface of the skin around the PEG tube. Although this does not usually cause excessive exudate and drainage, it is a source of moisture underneath the bolster, which can lead to breakdown of the skin.
60
How is hypergranulation tissue around a PEG treated?
The hypergranulation tissue may be trimmed with scissors and then treated with silver nitrate sticks or any other cautery device. Topical steroid cream may also be considered as a treatment method.
61
The ideal sodium concentration for oral rehydration solutions depends on the segment of ___ lost
-Depends on the segment of BOWEL lost
-e.g., jejunum, ileum, or colon.
62
Patients with short bowel syndrome who do not have a colon often require slightly ___ or ___ oral rehydration solution to promote maximal fluid absorption and reduce secretion.
Hypoosmotic or isotonic
63
The optimal sodium concentration of oral rehydration solutions ranges from ___ - ___ mEq/L to promote jejunal absorption.
90-120
64
EN initiation should be delayed until the patient is fully volume resuscitated and hemodynamically stable to reduce the risk of ___ ___
Intestinal ischemia
65
True or false: Evidence of bowel function, including bowel sounds or bowel movements, is required prior to the initiation of EN.
False: Evidence of bowel function, including bowel sounds or bowel movements, is not required prior to the initiation of EN.
66
Should refeeding risk delay nutrition support?
NO. Patients at risk for developing refeeding syndrome should be identified prior to initiation of nutrition support, but the risk of refeeding should not delay EN initiation.
67
How should nutrition support be initiated/advanced in patients at refeeding risk?
A patient thought to be at refeeding risk should be cautiously advanced toward the energy goal as dictated by clinical status and/or stable electrolyte levels.
68
What is the best route of EN for a patient with reduced consciousness?
EN should not be delayed with reduced level of consciousness, but post pyloric enteral access is recommended to decrease the risk of aspiration since this patient population is at increased risk of aspiration.
69
Any new occurrence of pain at or near the tube site should be promptly evaluated by the patient's ___ or ___ nurse.
Gastroenterologist or enterostomal nurse.
70
Describe buried bumper syndrome
Buried bumper syndrome results from erosion of the internal bolster into the gastric mucosa and/or wall and occurs in 0.3%–2.4% of patients. Excessive traction on the internal bolster slowly pulls it into the gastric wall as the mucosa grows over it.
71
Pain at the PEG site may indicate the presence of ___ or pressure ___.
Infection or pressure necrosis.
72
Weight gain after tube placement places a patient at greater risk for ___ ___ and ___ at the tube site due to increase in abdominal girth
Pressure necrosis and ulceration
73
The viscosity of an enteral formula depends on the concentration and characteristics of the ___ and ___.
Macronutrients and fiber.
74
An increase in the accumulation of formula sediment in the inner lumen of the enteral access device (EAD) is seen more often when a high ___ or high ___ formula is used.
-Fiber
-Protein
75
In terms of end of life: During starvation, the body begins to use ___ as the predominant energy source leading to increased ___ production with a resulting euphoria. Feeding even small amounts can prevent ___ and prolong the sense of hunger.
-Fat
-Ketone
-Ketonemia
76
The most common symptom when feeding or fluids are withheld is ___ ___, which is easily alleviated with good ___ care.
-Dry mouth
-Mouth
77
Intravenous hydration in the terminal patient can raise the risk of patient ___ and ___ distress.
-Discomfort
-Respiratory
78
Bolus feedings provide a set volume of formula at specified time intervals. Feedings are infused over a short period of time, over as few as ___-___ minutes, three to six feedings daily.
4-10 minutes
79
Intermittent feedings are commonly delivered by enteral pump or gravity drip method over a period of ___-___ minutes, four to six feedings daily.
20-60
80
What are the benefits of bolus and intermittent feedings?
Bolus and intermittent feedings may mimic normal meal times, provide additional flexibility, and be administered at home.
81
What type of feeding regimen is the preferred method for critically ill or mechanically ventilated patients?
Continuous feedings deliver formula via a pump-assisted continuous drip infusion. This is the preferred method for critically ill or mechanically ventilated patients.
82
Cyclic feedings are similar to continuous feedings except the formula delivery rate ranges from ___ hours to < ___ hours. This type of feeding may be used to transition a patient from continuous feedings, or to increase the patient's volitional intake.
-8
-24
83
What is the most common complication following gastrostomy placement?
Peristomal infection
84
Foul-smelling drainage around the feeding tube exit site is a sign of ___.
Infection
85
Early recognition and treatment of exit site infections reduces ___ and ___.
Morbidity and mortality
86
What can reduce the complication of leakage around the gastrostomy site?
Exit site care, proper outer bumper placement and prevention of tension on the tube help reduce gastrostomy exit site leakage.
87
What recovers faster in post-op patients: gastric emptying or small bowel motility?
Recovery of gastric emptying may be slower than return of small bowel motility in postoperative patients.
88
Small bowel feeding may increase the amount of feeding delivered in patients with high ___.
GRVs
89
Prone positioning in a patient with elevated GRVs may increase the risk of ___.
Aspiration
90
What type of medication may increase motility?
Prokinetic agents such as metoclopramide and erythromycin are used to increase motility
91
Name some reasons abdominal distention while receiving enteral nutrition may occur?
1. Rapid administration of feeding (i.e. bolus feeds)
2. Use of hyperosmolar solution (i.e. concentrated formulas)
3. Medications that slow peristalsis (i.e. pain relievers, anticholinergics)
4. Excess air in the stomach or intestines
5. Tube migration from stomach to small intestine
6. Infection
7. Cold formula
8. Inadequate fluid provision leading to constipation
9. Bacterial contamination
10. Fat, fiber or lactose intolerance
92
What is the treatment for abdominal distention in the tube fed patient?
Aggressive bowel regimens need to be considered in these patients to reduce distention and prevent impaction.
93
Holding enteral feedings for abdominal distention is generally not indicated unless abdominal girth exceeds the baseline measurement by at least ___ to ___ cm.
8-10
94
Agents such as narcotics or diphenhydramine have well documented anticholinergic effects often resulting in ___.
Constipation
95
Fiber may help to promote regular bowel movements in patients receiving enteral nutrition, but may also lead to excess ___ production and ___ abdominal distention
-Gas
-Increased
96
True or false: Providing additional free water flushes may help to decrease constipation
True
97
When might an NGT placement be difficult?
The procedure is difficult in uncooperative patients, patients with anatomic abnormalities, and in critically ill patients in which swallowing is inhibited.
98
An oral or nasoenteric small bore feeding tube is usually indicated when duration of EN therapy is anticipated to be less than ___ ___.
4 weeks
99
All enteral access devices are prone to clogging. Name some usual causes.
-Usual causes include suboptimal flushing
-Not flushing before and after each medication administration
-Accumulation of pill fragments
-Protein or fiber formulae
-Checking GRVs
100
___ is the superior fluid choice to maintain EAD patency
Water
101
EADS should be flushes with ___ml water every ___ hrs during continuous feeds, before and after intermittent feedings and after GRV measurements
-30mL
-4 hours
102
Tubes should be flushed with ___mL water before, between and after medication administration and at least ___mL if fluid restricted.
-15mL
-5mL
103
Short term EAD should be changed every 4-6 weeks to prevent what 3 complications?
Sinusitis, skin breakdown and fistulae
104
___ water flushes are indicated to maintain small-bore EAD patency.
Manual
105
Generally, enteral products designed for oral use contain more ___ to improve palatability.
Sucrose
This translates into a higher carbohydrate to protein and fat ratio.
106
Most enteral products for oral use provide approximately ___% to ___% of total calories from carbohydrate, ___% to ___% from protein, and ___% to ___% from fat.
-40-60% from carbs
-15-25% from protein
-15-35% from fat
107
Are there adequate vitamins and minerals in oral supplements?
The Daily Reference Intakes (DRIs) for vitamins and minerals may be met by ingesting a portion of oral supplements daily.
108
Do oral nutrition supplements contain both soluble and insoluble fiber?
A blend of soluble and insoluble fibers are typically found in oral formulas
109
Is a high GRV associated with aspiration?
The significance of GRV is controversial due to the lack of well-powered studies. Because of this, the relationship of GRV and aspiration pneumonia can't be clarified.
110
True or false: gastric residuals as part of routine care in ICU patients is not recommended
True!
111
If a patient is showing outward signs of intolerance gastric residuals can be measured. Enteral nutrition should not be held for GRV less than ___ ml.
500
112
Intermittent feedings are generally an amount of ___ to ___ mL administered over ___ to ___ minutes several times daily with or without a feeding pump
-240-720 mL
-20-60 minutes
113
Cyclic feedings are generally administered over ___ to ___ hours per day, depending on the patient's volume tolerance.
-8-16 hours
114
Bolus feedings are generally an amount of ___ to ___ mL delivered by gravity or a syringe over ___ minutes into the stomach
-240 to 480 mL
-15 minutes
115
Decreased level of ___ is a major risk factor for aspiration.
Consciousness
116
Name some risk factors for aspiration.
1. Reduced consciousness
2. Neurologic defect
3. Delayed gastric emptying
4. Gastroesophageal reflux disease
5. Supine position
6. Vomiting
7. Bolus enteral feedings
8. Mechanical ventilation
9. Age > 70 years
10. Poor oral care
117
Describe the closed enteral feeding system container
Purchased as bags or rigid containers filled with sterile enteral nutrition formula.
118
How is microbial contamination reduced in closed enteral feeding systems?
Minimum manipulation is possible secondary to the design of the containers helping decrease the risk of microbial contamination.
119
Closed system enteral feeding systems have longer hang time (___-___ hours) and requires decreased nursing time for administration.
24-48
120
Jejunal feeding is usually delivered ___ via pump.
Contiously
121
What complications may arise from bolus or gravity feeds into the jejunum?
Bolus or gravity feeding via jejunostomy may cause intolerance such as abdominal bloating, diarrhea.
122
Why might bolus or intermittent gravity feeds be better tolerated into the stomach?
Gastric feeding can be given as bolus or intermittent gravity methods since the stomach can hold larger amounts.
123
What are some benefits of cyclic tube feeding?
Cyclic feedings during the night are frequently used as patients are transitioning from enteral feeds to oral intake. Time off of tube feeding during the day often increases appetite.
124
What patient populations might benefit from an ORS to prevent dehydration?
Use of oral rehydration solutions (ORS) may help to prevent dehydration in patients with short bowel syndrome (SBS) and an End-jejunostomy.
125
___ is an important component in ORS as it promotes salt and water absorption.
Glucose
126
Hyper- or hypo-tonic solutions are not well absorbed and may increase ___ diarrhea in patients with SBS.
Osmotic
127
Does ASPEN recommend checking GRVs?
The Society of Critical Care Medicine (SCCM)/ASPEN 2016 guidelines suggest that GRV should not be used as part of routine care to monitor EN.
128
Commercial sports drinks are considerably ___ in sodium and ___ in carbohydrate content than ORS.
-Lower
-Higher
129
What is a potential complication of checking GRVs?
Gastric tubes are reported to clog more frequently than small bowel tubes secondary to intact protein formulas coming in contact with acidic gastric fluid.
130
Flushing feeding tubes with ___ mL of free water following GRV measurement in adult patients is recommended to prevent tube occlusion associated with GRV measurement.
30
131
What is the reverse Trendelenberg position?
The reverse Trendelenberg position is used when elevated backrest is contraindicated to elevate HOB (head of bed).
132
Why would it be helpful to put air into the gastric feeding tube?
The instilling of air into gastric feeding tubes is useful for increasing negative pressure when drawing GRV from small bore feeding tubes.
133
Human breast milk (HBM) should have a hang time of no longer than ___ hours. In addition, the tubing and syringe should be changed every ___ hours.
-4 hours
-4 hours
134
Administration sets used for human breast milk should be free of what?
Di(2-ethylhexyl) phthalate (DEHP) free and bisphenol A (BPA) free
135
What safety measures should be taken when preparing and administering human breast milk for the hospitalized neonate, infant, or child?
Milk should be prepared in a clean environment using aseptic technique by specially trained personnel.
Current recommendations also support the use of gloves during HBM administration.
136
What is the #1 researched key to preventing aspiration in all patients (including those fed enterally)?
Good oral hygiene, such as brushing teeth and rinsing with mouthwash daily
137
What are ASPEN/SCCM guidelines for reducing aspiration?
1. Lower GI placement in critically ill patients at risk for aspiration OR have shown intolerance to gastric EN
2. Maintaining the head of bed at 30 - 45 degree
138
Impaction can be manifested by symptoms of ___.
Diarrhea
Passage or secretion of fluid around the impaction may be responsible for the loose stool.
139
Can a patient with impaction have bowel movements?
Yes, the patient may intermittently pass small volumes of liquid stool and experience abdominal distention and cramping.
140
What are some factors that lead to constipation?
Fluid restriction, physical inactivity and narcotic usage lead to constipation.
141
What is the most prevalent electrolyte abnormality in refeeding syndrome?
Although hypokalemia, hypomagnesemia, and hypocalcemia may occur in refeeding syndrome, hypophosphatemia is most prevalent
142
Should all patients be included in refeeding protocols? Or just those at risk?
Patients considered not at risk should also be included since methods for screening at risk are inadequate.
143
What should a refeeding protocol include?
The protocol should replete all electrolytes via the intravenous, oral or enteral route depending on the condition of the patient and ability to tolerate oral repletion.
144
In the case of refeeding, feeding should not be delayed but instead initiated slowly and then advanced based on ___ levels and clinical ___.
-Electrolyte
-Response
