Exam 2: Enteral Nutrition Flashcards
Explain the steps in the decision making process for if, when, and how to provide nutrition support
(1) anticipated length of time enteral feeding will be required, (2) degree of risk for aspiration or tube dis- placement, (3) patient’s clinical status, (4) adequacy of digestion and absorption, (5) patient’s anatomy (e.g., after previous surgical resection or in extreme obesity), and (6) whether future surgical intervention is planned.
Identify 4 conditions that my require enteral nutrition
- impaired nutrient intake
- inability to consume adequate nutrition orally
- impaired digestion, absorption, metabolism
- severe wasting or depressed growth
What situations do patients have impaired nutrient intake?
neurological disorders, trauma, congenital anomalies, respiratory failure, traumatic brain/spinal cord injury
In what situations do patients have the inability to consume adequate nutrition orally?
Hyperemesis of pregnancy; hypermetabolic = burns; anorexia in
congestive heart failure, cancer, COPD
In what situations do patients have impaired digestion, absorption, or metabolism?
Severe gastroparesis, inborn errors of metabolism (GI), Crohn’s
disease, short bowel syndrome
In what situations do patients have severe wasting or depressed growth?
Cancer
Cerebral palsy
Cystic fibrosis
FTT
Myasthenia gravis
Sepsis
Describe proposed benefits of enteral nutrition vs. parenteral nutrition
Better gastrointestinal barrier function
More “physiologic”
Preserved gastrointestinal immunity
Preserved gut-associated lymphoid
tissue (GALT) activity
Microbiome support
Decreased rates of infection
Distinguish between the tubes used for enteral nutrition
- Nasogastric
- Nasoenteric
- Gastrostomy
- Gastrojejunal
- Jejunostomy
- Transgastric Jejunostomy
Nasoenteric complications
Esophageal strictures
Gastroesophageal reflux resulting in aspiration pneumonia Tracheoesophageal fistula
Incorrect position of the tube leading to pulmonary injury
Mucosal damage at the insertion site
Nasal irritation and erosion
Pharyngeal or vocal cord paralysis
Rhinorrhea, sinusitis, otitis media
Ruptured gastroesophageal varices in hepatic disease
Ulcerations or perforations of the upper gastrointestinal tract and airway
Nasogastric patients
-nose to stomach
- medication or feeding
- than 3 to 4 weeks
Nasoduodenal or Nasojejunal patients
- Patients who do not tolerate gastric feedings
- ## short term
What are the 3 access sites for EN?
Nasal
Oral
Abdominal
patient feeding tube if less than 4 week/
- naso enteric
- oral enteric
patient feeding tube if greater than 4 week?
- gastrostomy
- jejunostomy
- transgastric jejunostomy
- gastric/jejunostomy
What are the 5 feeding schedules for EN?
- Continuous
- Intermittent and Cyclic
- Gravity Drip or Bolus
- Low Dose “trophic feeding”
- Initiate “Full Strength”
What is Continuous feeding schedule?
- duration of 224 hours
Typical patients receive Continuous feeding
Critical care, ICU patients
What is intermittent and Cyclic feeds?
- duration of 8-20 hours
- depend on medication, procedures, and weaning
What is Gravity Drip or Bolus Feeding?
- used to assimilate normal feeding pattern
- 500mL/feeding
What is low dose “trophic feeding”
- ICU
- determine how patient tolerates feeding
What is initiate full strength?
- introduce all formulas at full strength, meaning that it is not diluted
What is isotonic
- 1 to 1.2 formulas
What is hypertonic
- more particles per volume
what is normal osmo of GI
What are open system feeding?
feeding
bag with cans
Higher risk of
contamination
o More frequent bag
and tubing changes
o No more than 8
hours of hang time
What are closed system feeing?
- Closed System: “Ready
to hang”
o Decreased risk of
contamination
o Room temperature,
stable up to 36-48
hrs
Hang time
Hang time is the length of time an enteral formula hanging at room temperature is considered safe for delivery to the patient. Most facili- ties allow a 4-hour hang time for a product in an open system and 24 to 48 hours for products in a closed system (manufacturer’s directions should always be followed).
Describe the nutrient composition of various enteral nutrition formulas
Protein (8-25% of total kcals)
* Predominant sources=soy, whey and casein
* BCAA’s
* Small peptide and AA’s
Carbohydrates (40-75% of total kcals)
* Predominant sources=hydrolyzed cornstarch,
maltodextrin
* corn syrup, fructose, glucose oligosaccharides
Fat (15-45% of total kcals)
* Predominant sources=polyunsaturated fats such
as corn, safflower, sunflower, or soybean oil
* Medium chain triglycerides (MCT) Note: do not
require hydrolysis by bile salts or pancreatic
lipase, BUT no EFA. Made from fractionated
coconut oil.
* Omega 3 fats (ARDS, Immunonutrition, metabolic)
What s the Fiber content in EN?
Soluble or Insoluble?
Soy Polysaccharide
Content ranges from 0-14
gms/liter
Consider recommended intake
of fiber (20-35 gms/day)
Modular: Benefiber,
Fibersource.
* One packet=1 tbsp., 3 gms fiber
What are the 3 disease-specific formulas
Renal
hepatic
Diabetic
Describe Renal Formula
Calorically Dense-2 kcals/mL
* Considerations include:
* Level of renal function
* Non RRT vs RRT
Describe Hepatic Formula
BCAA’s (valine, leucine, isoleucine) vs AAA’s
(phenylalanine, tyrosine, tryptophan) with
Hepatic Encephalopathy
* MCT fat source (0-66%), total fat 12-30%
* 1.5 kcals/ml
Describe Diabetic Formula
Carbohydrate Source: oligosaccharides,
fructose, cornstarch
* Soluble fiber (guar, pectin) Improved glycemic
control via delay of gastric emptying and
increased transit time
* Kcal distribution: 34-40% CHO, 42-50% FAT
(small % of MCT oil)
* Avoid overfeeding, appropriate insulin
management
What is Respiratory Disease “oxepa”
Acute Respiratory Distress
Syndrome (ARDS)
óFISH OILS/Borage Oil:
-Linolenic (GLA) and
Eicosapentanoic acids
(EPA). ? Favorable
conditions for pro-
inflammatory mediators
ó55% of kcals from fat
óVit E, beta-carotene,
selenium, Vitamin C
“Oxepa”
What are the specialty formulas and modulars
Critical Care/Metabolic
Formulas
Immunonutrition
Formulas
* Indications-?
* Omega 3 PUFA’s, Nucleic Acids,
Selenium, Vitamins A, C, E, Zinc,
Glutamine, Arginine
Glutamine
Arginine
Identify markers to monitor in patients receiving nutrition support
Body temperature
Intake/output Records
Glucose
Electrolytes: (NA,K,Mg,Ca,PO4,CL)
Renal function
Albumin/TP
Cholesterol/Trigs
H/H-iron status
Nitrogen balance
Prealbumin/CRP
WTS!!!!
Recognize potential complications of enteral nutrition
Gi complications
Mechanical Complications
Describe Gi complications
Diarrhea: >3-4 stools per day or >
250-500mL of liquid stool every 8
hours
Nausea and/or vomiting
Constipation: no stool for >3 days
Gastric residuals: > 200-500mL
Food/Drug interactions
Describe Mechanical Complications
- Pulmonary Aspiration
- Tube obstruction
- Mucosal damage
Nutrition Support Decision if the patient is meeting needs orally?
no further intervention need, cotinue to onitor
Nutrition Support Decision if the patient is not meeting needs orally and has nonfuncional GI tract?
Provide Parenteral nutrition
Nutrition Support Decision if parenteral nutrition needs are required for greater than 3 weeks
Peripheral extended dwell catheters
or
Central tunneled catheters and ports PICC
Nutrition Support Decision if parenteral nutrition needs are required for less than 3 weeks
Peripheral standard IV catheters
or
Central standard central lines
Nutrition Support Decision if the patient is not meeting needs orally but still requires fortified food and oral supplements >75% of needs
provide enteral gastric feeding
