Enteral Nutrition Support (part 3) Flashcards
What are some mechanical complications of enteral nutrition?
-Nasopharyngeal irritation
-Skin irritation
-Tube displacement
-Tube obstruction
What are some GI complications of enteral nutrition?
-N/V/D/C
-Abdominal bloating
Delayed gastric emptying
What are some metabolic complications of enteral nutrition?
-Electrolyte imbalances
-Fluid imbalances
-Overfeeding/underfeeding
-Refeeding syndrome
-Essential fatty acid deficiency
What complications can occur with administration of tube feeding?
-Microbial contamination
-Aspiration pneumonia
Tube obstruction can be caused by…
-Inadequate irrigation of feeding tube
-Medication interactions
-Undissolved formula due to insufficient mixing
-Adding modular products
-Precipitation of caseinates in formula due to adding acidic substances (e.g., fruit juice) to the tube feeding
-Homemade blenderized TF that isn’t thoroughly liquified
What can be done to prevent tube obstruction?
-Follow appropriate procedure to mix and administer tube feeding formulas and modular products
-Flush with a minimum of 30 mL water every 4 hours for continuous or cyclic feeding and before and after each bolus or intermittent feeding
To unclog a tube, instill ___ ___ with a 30-60 mL syringe into a tube and let sit for about 20 minutes
Warm water
If the tube remains clogged, instill ____ ____ ____ solution mixed with a small amount of water
Uncoated pancreatic enzyme
What are factors that increase the risk of aspiration?
-Body position (supine, Trendelenberg position)
-Displaced feeding tube
-GERD
-Large-diameter nasoenteric tubes
-Neuromuscular disorders
-Decreased consciousness/sedation
-Vomiting
-Bolus feeding
What can be done to prevent aspiration?
-Good oral care
-Elevate HOB to >30-45 degrees
-X-ray confirmation of nasoenteric tube position after placement
-Mark nasoenteric tube, monitor placement, and verify placement before each feeding
-Monitor for signs of GI intolerance every 4 hours
-Continuous feeding
-Position feeding tube distal to the ligament of Treitz (jejunum)
Enteral ___ ___ was previously used to monitor for aspiration (FD&C blue #1, Methylene blue), but is no longer recommended
Food dye
Why is enteral food dye not recommended?
-Not a sensitive indicator of early aspiration
-In critically I’ll patients, dye has been absorbed, leading to mitochondrial toxicity and death
What are causes of diarrhea that are unrelated to tube feeding?
-Medications
-Enteric pathogens (C. diff)
-GI disorders
What medications may lead to diarrhea?
-Antibiotics
-Medications containing sorbitol
-Prokinetic agents
-Antineoplastic agents
What are some causes of diarrhea related to tube feeding?
-Bolus feeding into the small bowel
-Rapid infusion of hyperosmolar formula into the small bowel
-Intolerance to a specific component of the formula
-Microbial contamination of feeding
Nutritional management of diarrhea:
-Determine cause of diarrhea
-Provide adequate fluid and electrolytes
-Change to an isotonic formula
-Change to a formula containing soluble fiber
-Continuous administration
-If fat malabsorption, use a semi-elemental formula containing MCT oil
What are ways to reduce the risk of microbial contamination?
-Used pre-filled, closed system formulas
-Wash hands before handling products
-Check expiration date
-Refrigerate unused portion of formula immediately (cover, label, date) and discard after 24 hours
-Change feeding bag and administration set every 24 hours
-Avoid unnecessary additions to tube feeding
-Limit hang time
Guidelines for hang-time of tube feeding:
Limit hang time to no more than
-24 hours for closed system
-4-8 hours for open system/canned formulas (4 hours if modular components are added)
-4 hours for reconstituted formulas
-2 hours for blenderized whole food formulas (homemade)
Symptoms of delayed gastric emptying:
-Gastric distention and discomfort
-N/V
Consequences of delayed gastric emptying:
-Increased risk of GERD and aspiration
Delayed gastric emptying can be caused by…
-Gastric ileus
-Medications (opioids)
-Supine position
-Pyloric obstruction
-Diabetic gastroparesis
-Whipple surgery
-Increased intracranial pressure
-Hypotension; sepsis
-EN formula with high fat content
-EN formula with high soluble fiber content
Ways to prevent/manage delayed gastric emptying:
-Elevate HOB during feeding and for 30 minutes after feeding
-Monitor abdominal girth
-Continuous TF administration
-Switch to a low-fat, low-fiber EN formula
-Ambulation if possible
-Tube tip placed past the ligament of Treitz
The nurse should check ____ ____ ____ every 4 hours for the 1st 48 hours a patient is on tube feeding
Gastric residual volume
The practice of using gastric residual volume as a monitor of tube feed _____ has been questioned
Tolerance
We should monitor for a ____ of increasing residual volume
Trend
If gastric residual volume is _____ or more mL after the second residual check, a promotility agent should be considered
250
An example of a promotility agent is ____
Metoclopramide (Reglan)
If gastric residual volume is over ____ mL, hold tube feed and reassess patient status
500
If a patient’s gastric residual volume is consistently over 500 mL, consider feeding tube placement below the ___ ___ ___
Ligament of Treitz
____ ____ is a constellation of metabolic alterations that occur within the first few days of refeeding a starved patient
Refeeding syndrome
Refeeding syndrome is due to a rapid shift of electrolytes from the bloodstream to cells due to insulin, leading to…
-Hypophosphatemia
-Hypomagnesemia
-Hypokalemia
Refeeding Syndrome can cause symptoms like…
-Respiratory distress
-Parethesia
-Lethargy
-Edema
-Muscle weakness
-Cardiac arrhythmias
-Hemolysis
Refeeding syndrome can be ____-____
Life-threatening
Someone is at significant risk of refeeding syndrome if they have any 1 of the following risk factors:
-BMI <16 kg/m2
-Weight loss 7.5% in 3 months or >10% in 6 months
-Caloric intake (none for >7 days, or 50% of EER for >5 days, or <50% of EER for >1 month)
-Low levels of potassium, phosphorus, or magnesium before feeding
Someone is at a moderate risk of refeeding syndrome if they have any 2 of the following risk factors:
-BMI 16-18.5 kg/m2
-Weight loss of 5% in 1 month
-Caloric intake (none for 5-6 days, or <75% of EER for >7 days or <75% of EER for >1 month)
-Low levels of potassium, phosphorus, or magnesium before feeding
For those at risk of refeeding syndrome, enteral nutrition can be initiated at a low rate on day 1 (____% of estimated calorie goal) can advanced cautiously over 3-5 days towards the goal
25
Someone at risk of refeeding syndrome should be supplemented with ___ mg of thiamin before initiating tube feeding
100
100 mg of thiamin should be continued for 5-7 days longer in patients with…
-Severe starvation
-Chronic alcoholism
-High risk or signs of thiamin deficiency
For those at risk of refeeding syndrome, we should monitor ____ daily for the first 5-7 days of refeeding and replete as needed
Electrolytes
What medications increase the risk of clogging?
-Cholestyramine
-Ciprofloxacin suspension
-Metoclopramide syrup
-Ferrous sulfate elixer
Tube feeding decreases the _____ of Dilantin (phenytoin)
Bioavailability
MNT for Dilantin:
-Hold tube feed for 1-2 hours before and after giving the drug
Continuous tube feeding should be initiated at a rate of ____-____ mL/hour
20-50
We can increase the feeding rate by ___-___ mL every 8-12 hours until goal volume is reached
10-20
The max rate for continuous tube feeding is ____ mL/hour
125
For hyperosmolar formulas administered directly to the small bowel, initiate at a ___ __ and increase rate more slowly
Low rate
For bolus and intermittent tube feeding administration, begin with ____ mL of formula every 4 hours
120
For bolus and intermittent tube feeding, we can increase the volume by ___-___ mL every 8-12 hours as tolerated until goal volume is reaches
60-120
What should we monitor for a patient on tube feeding?
-Overall tube feeding tolerance (GI status: symptoms, stool output, abdominal distension, gastric residual volume for gastric feeding)
-Presence of complications
-Weight: at least 3x/week
-Nutrient intake: actual volume of TF received, determine adequacy
-NFPE
-Hydration status: daily fluid I and Os, Na, BUN, Osmolality, physical assessment
-Serum electrolytes, BUN, creatinine: daily until stable, and then 2-3x/week
-Clinical status
