Enteral & Parenteral Nutrition Flashcards
Which patient has a higher risk for malnourishment - a mobile patient or one on bedrest?
- patient on bedrest
- often more ill
- decreased appetite because less energy expenditure
What type of diet should a patient with renal failure adopt?
Low protein; easier on kidneys
What is malnutrition?
- Includes both the deficiency or excess or imbalance of energy, protein and other nutrients
1) Under-nutrition resulting from insufficient food intake
2) Over-nutrition caused by excessive food intake
3) Specific nutrient deficiencies
4) Imbalance due to disproportionate food intake
Those who are malnourished are 2x more likely to…
Develop a pressure ulcer
What percentage of malnutrition is disease-related?
76%
T or F: malnourished patients are more likely to die in hospital
True; 7.4x more likely
T or F: malnourished patients are more likely to be readmitted
True; 1.6x higher odds
Malnutrition is associated with an increased risk of….
- morbidity in acute and chronic diseases
- infections
- post-op complications
- mortality
- pressure wound ulcers
- poor wound healing
- delayed functional improvement
- increased length of stay
- increased readmission rates
- delay in the initiation of adjunctive treatment
What is one of the best indicators of malnutrition risk?
Involuntary weight loss of 10% of usual body weight preceding 6 months of hospital admission
What 4 basic questions can nurses ask upon admission for the early identification of nutritional risk?
In order of importance:
- Have you lost weight in the past 6 months?
- If yes, how much weight have you lost and over what time frame?
- What is your current weight?
- What is your height?
What 2 questions does the Canadian Nutrition Screening Tool?
- Have you lost weight in the past 6 months without trying?
2. Have you been eating less than usual for more than a week?
What is the cause of malnutrition in the hospital?
- in developed countries, the cause is disease not starvation
- pro-inflammatory effect of illness is the culprit
- any disease has the potential to cause malnutrition: response to trauma, infection or inflammation may alter metabolism, appetite, absorption or assimilation of nutrients
- poor intake in hospital also due to organizational or patient factors
What are 8 organizational factors that result in poor intake?
- lack of nutrition awareness by HCPs and patients
- inappropriate NPO status
- multiple medical tests requiring fasted states
- unprotected meal times (diagnostics, visitors, transfers) – staff may forget to give food to patient when meal is missed
- adverse hospital smells and noises
- lack of assistance at meals
- food services issues (unpalatable food, cold food, selective options)
- lack of nutritious food options outside of meal times
What are patient factors that result in poor intake?
- illness effects (poor appetite, too sick, tired, or in pain)
- eating difficulties (cannot open or unwrap food, uncomfortable position, difficulty reaching food, difficulty chewing and swallowing)
Who is responsible for the nutritional health of hospitalized patients?
All health care employees
What are the 3 categories of clinical nutrition interventions?
1) Oral route
2) Enteral nutrition (tube feeding)
3) Parenteral nutrition (IV or total parenteral nutrition)
What are 3 interventions for the oral nutrition?
- optimize oral intake (snacks and preferences)
- food fortification (costly, unpalatable)
- oral nutrition supplementation (effective and cost friendly)
What are the indications for oral nutrition intervention?
- consistent with medical and patient’s goals
- inadequate oral intake to meet nutrient needs
- functional gastrointestinal tract
- safe functional swallow
What is automatic nutrition supplementation?
- all patients admitted to medical floor > 65 yo receive Ensure meal trays
- cost benefit and reduces length of stay and readmission rate
What is the benefit of adding nutrition supplementation to malnourished patients?
- increased QoL, reduced infections, decreased length os stay, fewer pressure ulcers
- patients identified at risk by screening tool in ER, received Ensure plus or Glucerna on meal trays automatically
Can nurses make a difference?
- consumption of 50-65% of meals and supplements can halt or minimize the catastrophic effects of hospital malnutrition
- can encourage, emphasize, and reinforce the importance of nutrition
How can nurses promote oral supplement compliance?
- encourage sampling of different flavours
- serve cold or with ice
- if nausea too strong or odours are an issue, serve with a lid and straw
- keep within patient’s reach
- encourage sips
- watch your facial expression
What is enteral nutrition?
Delivery of nutrients to the gastrointestinal tract via a tube
What are the indications for enteral nutrition?
- consistent with medical and patient goals
- oral intake is deemed unsafe, inadequate, or impossible to meet nutrient needs
- functional gastrointestinal tract
- accessible gastrointestinal tract
What are the benefits of EN vs TPN?
- safer than TPN
less expensive than TPN - preserves GI tract integrity and function
- reduce infectious and non-infectious complications associated with disease and injury
- patient may still be able to eat orally
What conditions may necessitate EN?
1) Impaired ingestion (intubation, facial or esophageal trauma, stroke)
2) Inability to consume adequate nutrition due to:
condition (hyperemesis of pregnancy, anorexia associated with CHF) or
a hyper-catabolic state (Bone Marrow Transplant, severe burns, sepsis)
3) Impaired digestion and absorption (pancreatic cancer, short bowel, pancreatitis, gastroparesis
)
4) Severe wasting/malnutrition
(End Stage Liver Disease awaiting transplant, severe Crohn’s disease)
What are contraindications for EN?
- non-operative mechanical GI obstruction
- intractable vomiting/diarrhea
- paralytic ileus
- severe GI bleed
- perforation of the GI tract
- inability to gain access to the GI tract
- aggressive intervention not warranted or not desired
What are the 2 enteral feeding routes?
1) Nasoenteric (nasogastric, nasoduodenal, nasojejunal)
- short-term (<3-4 weeks)
2) Percutaneous enterostomy (gastrostomy [PEG] or jejunostomy)
- long-term (>4 weeks)
How are EN routes chose?
Based on access and expected duration (NG short-term, PEG long-term)
Tube feeding supplies should be changed…
24 hours
What are polymeric formulas for EN?
- require digestive capability
- standard formula: CVA with swallowing dysfunction
- higher protein: post-surgery, pressure ulcer, burns, wounds, sepsis
- nutrient dense: hyper-catabolism, fluid restriction
What are semi-elemental formulas for EN?
- require minimal digestion for absorption
- easily digested and assimilated
- for gastrointestinal impairment such as gastroparesis
- or malabsorptive conditions such as pancreatitis or chemotherapy
- also depends on route; if going directly into intestines than protein should already be broken down
What are important steps to follow when administering EN?
- use aseptic technique
- label EN equipment
- elevate HOB 30 degrees
- ensure right patient, right formula, right tube
What are enteral misconnections?
- inadvertent connections between enteral feeding systems and
non-enteral systems such as intravascular lines, peritoneal dialysis
catheters, tracheostomy tube cuffs, and medical gas tubing - of low frequency but high consequence
- not one-size-fits-all
- international initiative to standardize enteral feeding tubes and connectors
Should EN be discontinued if the patient has diarrhea?
Not right away; do more investigation first
What are considerations for medication delivery via EN?
- preferred route is oral
- some require stomach acid to be activated
- medications can interact with the formula, don’t mix together
- many cannot be crushed (slow release or enteric coated)
- pharmacy has a list of meds and how to properly administer
- formula may need to be held for 1-2 hrs before and after a med (phenytoin, ciprofloxacin)
- flush, med, flush – give meds individually, do not mix or add to feeding container
What are potential complications of EN?
- aspiration
- nausea
- vomiting
- increased abdominal distention
- constipation
- diarrhea
- metabolic issues
- blocked/clogged tubes
- tube related issues
- tube misconnections
How is aspiration managed?
- turn off fed immediately
- minimize incidence by raising HOB > 30 degrees
How is nausea managed?
- rate may need to be reduced, or feeding can be paused for 1 hour then re-started at reduced rate
How is vomiting managed?
- RD may re-assess type of tube placement
- hold feeding if gastric feeding and emesis
- consult MD for anti-emetic, and/or pro-motility agent
How is increased abdominal distention managed?
- turn off feeding, consult MD
- review bowel habit and last BM
How is constipation managed?
- meds that may contribute or manage constipation may need to be reviewed
- may require fiber containing formula
- may require additional water flushing
How is diarrhea managed?
- multiple medications can worsen diarrhea, so may need to be reviewed
- rate of infusion may need to be re-assessed
- may benefit from different formula with more or less fat or fiber
What metabolic issues can arise?
- hyperglycemia
- refeeding syndrome (food delivered too quickly)
How are blocked/clogged tubes managed?
- attempt to flush with 60 mL of room temp. water
- attain tube feed unblocking kit
What are tube-related issues?
- leakage
- skin infection
- tube dislodgement
What is parenteral nutrition?
- also called total parenteral nutrition (TPN)
- infusion of a sterilized, specialized form of liquid nutrients through a vein into the bloodstream via an IV catheter
- needs to be completely elemental
What are indications for parenteral nutrition?
- consistent with medical and patient goals
- patients are unable to meet nutrition needs with EN
- pre-operative support in the severely malnourished patient
- gastrointestinal incompetency (paralytic ileus, small or large bowel obstruction unlikely to resolve within 5 to 7 days,
severe diarrhea with evidence of malabsorption,
intractable vomiting)
What is peripheral parenteral nutrition (PPN)?
- given through a peripheral vein
- short term use - 7 days
- limitations include: often unable to meet caloric needs, site must be rotated every 3-5 days, principle complication of thrombophlebitis
What is central parenteral nutrition (CPN)?
- infused into large central vein
- greater percentage of caloric and protein needs can be met
- more long-term
- pharmacy compounds the solutions under aseptic conditions to prevent bacterial contamination
- very important solution for CPN not put into PPN
What are contraindications for TPN?
- functional and usable GI tract
- prognosis does not warrant aggressive nutrition support, or is not desired by patient or guardian
- risks judged to be greater than benefits
- TNP is more dangerous and expensive
What are conditions necessitating TPN?
- hyper-metabolic state with poor enteral tolerance and accessibility
- ileus after major intra-abdominal surgery
- hyperemesis gravidarum when jejunal feedings are unsuccessful
- severely malnourished patients prior to and during an intensive intervention which precludes the use of the GI tract for at least seven days
- patients undergoing high-dose chemotherapy, radiation and or bone marrow transplantation when EN is unsuccessful
- severe acute pancreatitis where EN is unsuccessful
- pre-operative support in the severely malnourished patient
- supplemental TPN initiated when goal rate feeds cannot be achieved within 48-72 hours
- supplemental TPN initiated on admission during diagnostic work up
What is a PICC?
- for CPN or medications
- peripherally inserted central catheter
- threaded to subclavian vein
- tube is marked to ensure proper placement
What is a PORT?
- also for CPN
- inserted into chest under the skin via minor surgery
- the tube enters from the subclavian vein from the port site
What are complications of TPN?
- technical: pneumothorax, hemothorax, nerve injury, subcutaneous emphysema
- mechanical:
occlusion or fibrin sheath, thrombus - infections
- metabolic: refeeding syndrome, hyperglycemia (hypoglycemia less common, but can occur)
electrolyte or mineral abnormalities, hepatobiliary complications, metabolic bone disease
What steps does a RD take before initiating TPN?
- nutritional assessment
- venous access evaluation
- baseline weight
- baseline lab investigations
Once TPN initiated, what nursing actions should be taken?
- monitor vital signs, temperature, ins and outs
- check blood glucose
- inspect catheter site for signs of inflammation, infection or bleeding and placement
- visually check the solution/label (name, ID, expiry date, solution matches prescription, route of administration, leakage, emulsion stability)
- maintain aseptic techniques with all procedures related to the setup and administration of TPN and catheter care (site, flushing, hub)
- ensure TPN is delivered at the prescribed rate
- monitor catheters infusion ability “stiff flush”
- change IV q 24 hrs and with each administration of intermittent PN infusions
- discard solution if it has not been used for >4 hours
- check drug compatibility
What is refeeding syndrome?
- caused by rapid nutritional repletion in severely malnourished patients
- characterized by fluid and electrolyte disturbances: hypernatremia, hypophosphatemia, hypokalemia and hypomagnesemia
- can lead to fluid retention, heart and respiratory failure
- symptoms: edema, cardiac arrhythmias, muscle weakness, confusion
- monitor glucose, electrolytes, PO4 and Mg
for 3 days - low serum levels must be corrected prior to feeding
- feeds advanced slowly
Considerations for stopping TPN?
- wean TPN based on oral diet/initiation of enteral feeding
- in hospital, slow to 1/2 rate, then stop when patient is meeting 50-60% requirements orally or EN
- at home, decrease total calories/day or number of nights infused
The overriding premise of nutrition support is…
If the gut works, use it
The guiding principle of nutrition support is…
Use the least invasive and most physiologic method of feed; consider oral supplements, then EN, then PN
What are the goals of clinical nutrition intervention?
- to improve clinical status and outcome
- to restore/improve nutritional status in the face of disease and injury
- to possibly modulate/attenuate the disease process
- to minimize the catastrophic effects of injury, sepsis and inflammation
- minimize the rate of lean body mass catabolism and weight loss and work towards anabolism
- provide essential nutrients (macro and micronutrients)
- decrease infectious and non-infectious complications
- reduce length of stay, costs
- improve quality of life
