Home Enteral Nutrition Flashcards
the largest payer of home enteral and PN is
Medicare
education materials for home EN/PN should be at a ____ level
6-8th grade level
what should be evaluated on a home care provider performance improvement plan
hospital re admit rate (also, mortality rate, customer satisfaction, complications, problem reporting/resolution)
benefits of a home nutrition support team
earlier transition to PO or EN, avoids multiple lab draws, improved coordination of care, more psychosocial support, earlier identification of potential problems and deficiencies
a non-profit organization for education and support that is free to all home PN or EN patients
Oley Foundation
what are the benefits of a nutrition support support group
increased quality of life, decreased depression, decreased incidence of catheter related sepsis
how often should electrolytes be monitored in nutrition support
Initially: weekly until clinically stable
What makes a patient a good candidate for home EN
physical & emotional well being, willingness to go home, adequate storage pace, electricity, running water, phone in the home, patient support/support network, back up battery for powered infusion pump
Medicare: in order to be covered for a tube feeding pump at home you must have
nausea/vomiting, GERD, gastroparesis, dumping syndrome
in order to be covered for home enteral feeding ____ must not be possible
PO intake
according to medicare, permanence of EN or PN is defined as > ____ days
90 days
when an anatomic or motility disorder will interfere with oral intake for > 90 days, EN will be covered. True or False
True
for an enterally fed home patient, a pump will be covered if
intolerance to bolus or gravity feeding is demonstrated
Third Party insurance payers are the ____ likely to pay for EN formulas because they equate to the cost of a grocery bill
third party
the 3 most important monitoring for HEN patients who are stable are
weight, I/O and bowel function
if a PEG tube dislodges after the tract matures (>6 weeks) a replacement tube can be
reinserted and surgery is not required
if a PEG tube dislodges that has an immature tract, within ___ hours a dilator can be used to open the tract IN THE HOSPITAL NOT AT HOME
12
what is the best way to ensure the patient is performing proper tube feeding technique
return demonstration
To ensure the best adherence to feeding and improved psychosocial health of a tube fed patient their tube feeding schedule should be
integrated into the patient/family’s way of living and should simulate normal meal times
in a stable home EN patient, it would be most appropriate to routinely monitor
weight, intake/output, bowel fx
enteral feeding should be incorporated into the patient’s/families
lifestyle, mimic normal meal times
what is encouraged of family members of an enterally fed patient at home
participation, dinner table socializing
a home tube fed patient’s administration schedule should mimic
normal meal times
patient education materials should be at the ___ to ____ grade level
5th to 6th grade level
the best way to to know the patient/family’s understanding of EN delivery is
return demonstration/ teach back
an active process where the patient can demonstrate themselves and verbalize the process is called
teach back/ return demonstration
Teach Back/Return demonstration helps the patient/family get accurate _______, verify ______ and reinforce new home care ________
information
understanding
skills
the maximum hang time for an open enteral system IN THE HOME SETTING is
12 hours
the maximum hang time for a closed system in the HOME setting is
24-48 hours
the best way to care for the skin around a feeding tube is
mild soap and water, rinse and keep dry thoroughly, clean under the external bolster
when are dressings recommended for PEG tubes
only if there is drainage
the home care improvement plan for an enterally fed tube feeding patient measures ________ in the home tube feeding setting
outcomes
what NEEDS to be included in the home care improvement plan for home enterally fed patients
- hospital re admits
- complications
- patient/family satisfaction
- problem reporting/resolution
Under the Centers for Medicare and Medicaid Prosthetic Device Act, hone enteral nutrition patients (HEN) are only covered if they meet the criteria for permanent disease of the structures that ________________ or disease of the small bowel that impairs. WITH these 3 documented indicators
- permit the food to reach the small bowel
- digestion/absorption of a PO diet
- test of performance documented by MD
- statement of permanence (90 days)
- statement of needing to maintain weight/strength not possible by taking in oral nutrition supplements
- serum albumin <3.4 g/dL , fecal fat test
- weight loss >10% >/= 3 months
In enteral nutrition discharge instructions the following needs to be documented. Name of the _______, total ______, route of _______, care of the ________, product hang time, stability at room temp, inspection of the product, expiration dates , _____ prevention, what to do when you _______, phone number for the home care company and proper_____
- name of the formula
- total daily volume needed
- route of administration
- care of the enteral access device
- infection prevention
- run out of supplies
- storage
the most common complication associated with PEG tube placement is ____ which can occur within days to months
peristomal infection
examples of Medicare coverage part B conditions
obstruction 2/2 head/neck cancer
motility disorders
severe dysphagia
which conditions are not covered by medicare for home EN
anorexia, malnutrition, nausea
Medicare reimbursement for nutrition education by an RD is only covered for
diabetes
renal disease (pre dialysis)
kidney transplant
managed care / private insurance companies usually use ______ criteria for HPN coverage
medicare criteria
managed care/private insurance companies usually require _________ and medical _____ and sole source of ______ in order to cover EN
pre authorization
medical necessity
sole source of nutrition
how often initially should electrolytes, glucose, BUN, Cr, Mag, Phos be monitored
weekly for 4 weeks or until clinically stable
what type of venous access devices are indicated for home PN use
PICC lines (Hickman)
Implanted Ports
Tunneled CVCs
a permanent ____ must be placed before discharging home with HPN
venous access device (central)
upon initiation of home PN, initial lab data should be obtained when
prior to starting home PN
the patient/training policies for home PN should address
education
training
evaluation of the patient/caregiver competency
home infusion companies are responsible for the delivery of
- nutrition products
- supplies
- nursing care
- formula delivery
- equipment delivery
assessing of micronutrient status in HPN patients requires thorough ______
symptom observation
copper deficiency masks _____deficiency making it difficult to assess home PN patients
B12
Hypermagnesemia results from ______ in HPN patients
commercial trace element preparation
manganese is almost fully excreted by the ________
hepatobiliary system (bile)
try to decrease the dose of manganese in patients on HPN with
hepatobiliary disease or liver disease
who are at risk for a manganese toxicity
long term PN over 30 days with obstruction of the biliary duct
when there is a toxicity of manganese with inability to excrete it through the bile, it can deposit in the ______ especially with IV manganese
brain
what is the BEST way to detect manganese levels
whole blood manganese
what is the best indicator for chromium deficiency
there is NO known reliable indicator of chromium status
what are the roles of chromium
- potentiates the action of insulin
2. plays a role in glucose, protein and lipid metabolism
which populations are at risk for chromium deficiency
- pregnancy
2. Type 2 DM
if a patient is hyperglycemic, give ______ supplementation and see if the blood glucose resolves
chromium
what are some causes of zinc deficiency
inadequate intake, decreased absorption, increased losses, increased demand
primary symptoms of zinc deficiency
loss of taste, altered smell, rash, alopecia, gonadal hypofunction, night blindness
every HPN patient should get ____ daily unless there is a toxicity / potential for toxicity or national shortage
micronutrients
whenever a patient has a nutrient omitted what should be done
monitor for deficiency or toxicity that can develop over time
are lab values always the best indicators for normal micronutrient status
NO
normal lab values of micronutrients can give a false ______
sense of security
failure to monitor which long term micronutrient can result in toxicities of these micronutrients in PN: zinc, manganese, folate or molybdenum
manganese
hypermanganesemia can occur in all ____ patients regardless of liver function
long term PN patients
PN contains these potential toxic elements from an ASPEN 2009 review
manganese, copper, chromium
in the 2012 ASPEN recommendations, there was a recommended decrease of these trace elements
manganese and copper
symptoms of manganese toxicity
headache, Parkinson’s like abnormalities
Case: A malnourished patient with metastatic ovarian cancer is diagnosed with inoperable, partial SBO. She is taking in small amounts of a full liquid diet by mouth but is unable to take enough nutrition to maintain her weight. She has lost 12% of her body weight in the past 2 months. According to current Medicare guidelines the patient’s HPN will be covered under which of the following circumstances
- the medical record must document failure of EN feeding tube or explain why it is not an option
- it is critical to document a non functional GI tract
diagnosis of a SBO alone is _____ qualifying for HPN
Not
Large volume, small volume, pharmacy bulk PN components must be labeled with the amount of ______ anticipated to be in the product when the product _________
aluminum, expires
the amount of aluminum on PN labels are about ____________ than what is actually in the PN bag of an individual patient
10 times more
pharmacies are not require to list _____ content of each individual patient’s PN bag
aluminum
symptoms of aluminum toxicity
neurological, hepatic, hematologic, skeletal muscle
Sx are non specific, non sensitive, can include some metabolic bone disease but is not the primary symptom
the most practical way to manage micronutrients in long term PN patients is to
perform micronutrient assessment every 6 months including nutrient intake assessment, assessment for potential losses, medications/surgical history and a nutrition focused physical exam
what are the causes of nausea and vomiting in long term EN patients
rapid EN infusion, gastric outlet obstruction from tube migration, excessive feeding volume, gastroparesis
how is nausea and vomiting prevented in home EN patients
- decrease TF rate/volume of an EN infusion of N/V occurs
many third party payors (insurance companies) equate the cost of EN formulas to the cost of _____ and DON’T cover the expense
groceries
if a patient cannot afford their formula, what are their options
- work with an RD to find an alternative
2. there are non profit/indigent care programs to help
EN formula may be covered under Medicare Part _____ and is usually only covered to about ____%. Patients with supplemental ______ may have the rest of the 20% covered.
Medicare Part B
20%
Supplemental insurance
Home blenderized EN formulations should be discarded after _____ hours at home. Their hang time should be ____ hours.
Discard after 24 hours
hang time 4 hours
which non profit organization is a great resource for home PN/EN patients
Association of GI motility Disorders
a 69 year old male on a continuous, high-protein, high fiber tube feeding is running at 65mL/hr via a PEG. The TF was selected to assist with wound healing and diarrhea. The tube feeding is stopped every 6 hours , residuals are checked and the tube is flushed with 30mL of water. The patient is provided liquid medication via the PEG tube 2 times a day. The tube now seems occluded, why?
inadequate flushing
