Enteral Nutrition Part 3 Flashcards by Sydney Perry

Complications of Enteral Nutrition

Mechanical
GI
Metabolic
Administration

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Mechanical complications of EN

nasopharyngeal irritation
skin irritation
tube displacement
tube obstruction

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GI Complications of EN

N/V/D/C
abdominal bloating
delayed gastric emptying

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Metabolic Complications of EN

fluid imbalances
underfeeding
overfeeding
refeeding syndrome
EFAD
electrolyte imbalances

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Administration Complications of EN

microbial contamination
aspiration pneumonia

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TUBE OBSTRUCTION can be caused by…
inadequate _____ of feeding tube
______ interactions
adding _______ products

_____________ in formula due to adding _______
________ formula due to __________
homemade blenderized TF that isn’t ______

irrigation
medication
modular

precipitation of caseinates
acidic substances (ex: fruit juice)

undissolved
insufficient mixing
liquified

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TUBE OBSTRUCTION prevention

follow appropriate procedure to mix and administer the tube feeding and modular products

flush feeding tube with a minimum of 30 ml water every 4 hours for continuous or cyclic
- also before and after each bolus or feeding

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To unclog a tube, _____________

If tube remains clogged, instill _____________

instill warm water with a 30-60 ml syringe into tube and let sit for ~20 minutes

uncoated pancreatic enzyme solution mixed with a small amount of water

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Factors that increase risk of ASPIRATION

Body position _____________
________ feeding tube
______ (condition)
______ diameter nasoenteric tubes
___________ disorders
Decreased _________
_______
______ feedings

(supine) Trendelenburg position
Displaced
GERD
Large
Neuromuscular
consciousness/sedation
Vomiting
Bolus

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Prevention of ASPIRATION

Good _____
Elevate HOB to >_____ degrees

___________ of nasoenteric tube position after placement
Mark nasoenteric tube, monitor placement, verify placement ___________

Monitor for signs of ________ q ____
___________ feeding
Position FT distal to the __________

oral care
30-45

X-ray confirmation
before each feeding

GI intolerance, 4 hrs
Continuous
ligament of Treitz

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Causes of diarrhea unrelated to TF

medications
enteric pathogens
GI disorders

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enteric pathogens that can cause diarrhea

Clostridium difficile (C.diff)

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Medications that can cause diarrhea

antibiotics
meds containing sorbitol
prokinetic agents (reglan)
antineoplastic
Potassium supplement

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Causes of Diarrhea Related to TF

Bolus feeding into small bowel

rapid infusion of hyperosmolar formula into small bowel

intolerance to a specific component in formula

microbial contamination of feeding solution

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Nutritional Management of DIARRHEA

Most important thing is to _________
provide adequate __________
change to ______ formula
change to a formula containing ________
_______ administration

if fat malabsorption, use ________ formula with _____

Determine cause
fluid & electrolytes
isotonic
soluble fiber
continuous

semi-elemental
MCT Oil

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For flushing can u use tap

yes unless ICU, immunocompromised, or unsafe water

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how do you know there is a clog in tube

alarm on pump or resistance when feeding

To reduce the risk of MICROBIAL CONTAMINATION…
use ______, ______ formulas
______ before handling products
check _________

fridge unused portion of formula immediately, cover, label, date, and discard after ____

change feeding bag and administration set every ________
avoid unnecessary ______ to tube feeding

prefilled closed
Wash hands
expiration date

24 hours

24 hours
additions

Reducing the Risk of Microbial Contamination – Limit Hang-time to no more than:
____ hours for closed system
____ hours for open system/canned formulas
____ hours if modular components are added
____ hours for reconstituted formulas
____ hours for blenderized whole food formulas

24
4-8
4
4
2

Symptoms of delayed gastric emptying

gastric distention
discomfort
N/V

Consequences of delayed gastric emptying

increased risk of GERD and aspiration

Causes of Delayed Gastric Emptying

Gastric ileus
Medications (_____)
Supine position
_______ gastroparesis
_______ obstruction
_______ surgery
Increased __________
________; _____

EN formula with high ____ content
EN formula with a high __________ content

opioids
Diabetic
Pyloric
Whipple
intracranial pressure
Hypotension; sepsis

fat
soluble fiber

most commonly reported side effect of tube feeding

diarrhea (however mostly from something else)

Prevention and management of Diarrhea

Elevate HOB during feeding and for ____ after feeding

Monitor _________
________ TF administration
Switch to a ______, _____ EN formula
_________ if possible
Tube tip placed past ___________

30 min

abdominal girth
Continuous
lower fat, low-fiber
Ambulation
ligament of Treitz

Monitoring Gastric Residual Volumes (GRV) Nurse checks GRV q _____ for the first _____ practice of using GRV as a monitor of TF tolerance has been _______ Monitor for a trend of _________

4 hours 48 hours questioned increasing residual volumes

ASPEN GUIDELINES FOR GRV: If GRV > _____ ml after ____ residual check=> _________ should be considered=> ___________ If GRV > ______ ml=> ______, reassess patient status If consistently >_____ ml=> consider _______

250 2nd promotility agent metoclopramide (Reglan) 500 hold TF 500 FT placement below the ligament of Treitz

Constellation of metabolic alterations that occur within the 1st few days of refeeding a starved patient

refeeding syndrome

refeeding syndrome includes a rapid shift of _______ from _____ to ______ due to ______ leads to _____, ______, _____

electrolytes bloodstream cells insulin hypophosphatemia* hypomagnesemia hypokalemia

refeeding syndrome can cause

respiratory distress paresthesia lethargy edema muscle weakness cardiac arrhythmias hemolysis

TO IDENTIFY PPL AT RISK OF REFEEDING SYNDROME... SIGNIFICANT RISK IF ONE OF THESE: - BMI ____ - weight loss ________ or _________ - caloric intake of _________, ______, or ________ - low levels of ____, ____, or ____

<16 7.5% in 3 months >10% in 6 months None for >7 days <50% of estimated energy requirement (EER) for > 5 days during acute illness/injury <50% or EER for >1 month K+, Phos, or Mg

TO IDENTIFY PPL AT RISK OF REFEEDING SYNDROME... MODERATE RISK IF TWO OF THESE: - BMI ______ kg/m2 - Weight loss: ___________ - caloric intake of _______, ______, or ______ - Low levels of ____, _____, or ____ before feeding

16-18.5 5% in 1 month None or negligible for 5-6 days <75% of EER for >7 days during acute illness/injury OR <75% of EER for >1 month K+, Phos, or Mg

Refeeding Syndrome—Prevention & Treatment First step is to _________

identify patients at risk

How to prevent Refeeding syndrome with EN - EN can be initiated at a low rate on Day 1 (~___% of estimated goal) and advanced cautiously over ___ days toward the goal - Supplement with ________ before initiating TF - Continue for _____ days or longer in patients with severe _____, chronic _______, or if at high risk or signs of ______ deficiency - Monitor _______ daily for the 1st _____ days of refeeding and replete as needed

25 3–5 100 mg thiamin 5–7 starvation alcoholism thiamin electrolytes 5-7

Consider food-drug interactions with EN - Some meds increase risk of ______ Other big drug with food drug interaction with tube feeds is ______

clogging Phenytoin (Dilantin)

some meds that increase risk of clogging

cholestyramine ciprofloxacin suspension metoclopramide syrup ferrous sulfate elixer

Phenytoin (Dilantin) is ________ medication FDI is ________ MNT=>___________

Anticonvulsant TF decreases bioavailability of drug Hold TF for 1-2 hrs before & after giving drug

CONTINUOUS TUBE FEEDING - Initiation rate _____ ml/hr - Progression=> Increase feeding rate by ____ ml every ____ hrs until goal volume is reached - Maximum rate ___ ml/hr For ________ formulas administered directly to the small bowel or at risk for refeeding syndrome=> initiate at a low rate & increase rate more slowly

20-50 10-20 8-12 150 hyperosmolar

BOLUS & INTERMITTENT TF ADMINISTRATION Begin with _____ ml of formula per feeding Increase by ____ ml per feeding per day as tolerated until goal volume reached

120 120

MONITORING TUBE FEEDS - Overall tube feeding ______ - GI status=> symptoms; ____ output; abdominal distention; ____ (_____ feeding only) - Presence of complications - Weight=> at least _____ - Nutrient intake=> actual volume of TF received; determine adequacy

tolerance stool GRVs gastric 3x/week

MONITORING TUBE FEEDS - NFPE - Hydration status: Daily fluid I & O’s; Na, ____, ____; physical assessment - Serum ____, _____, _____ - daily until stable then _______ a week - Serum ______ – daily until stable then _____ - Clinical status

BUN Osm electrolytes, BUN, creatinine 2-3x/wk glucose weekly