Home Enteral Nutrition

Question 1

the largest payer of home enteral and PN is

Answer 1

Medicare

Question 2

education materials for home EN/PN should be at a ____ level

Answer 2

6-8th grade level

Question 3

what should be evaluated on a home care provider performance improvement plan

Answer 3

hospital re admit rate (also, mortality rate, customer satisfaction, complications, problem reporting/resolution)

Question 4

benefits of a home nutrition support team

Answer 4

earlier transition to PO or EN, avoids multiple lab draws, improved coordination of care, more psychosocial support, earlier identification of potential problems and deficiencies

Question 5

a non-profit organization for education and support that is free to all home PN or EN patients

Answer 5

Oley Foundation

Question 6

what are the benefits of a nutrition support support group

Answer 6

increased quality of life, decreased depression, decreased incidence of catheter related sepsis

Question 7

how often should electrolytes be monitored in nutrition support

Answer 7

Initially: weekly until clinically stable

Question 8

What makes a patient a good candidate for home EN

Answer 8

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

Question 9

Medicare: in order to be covered for a tube feeding pump at home you must have

Answer 9

nausea/vomiting, GERD, gastroparesis, dumping syndrome

Question 10

in order to be covered for home enteral feeding ____ must not be possible

Answer 10

PO intake

Question 11

according to medicare, permanence of EN or PN is defined as > ____ days

Answer 11

90 days

Question 12

when an anatomic or motility disorder will interfere with oral intake for > 90 days, EN will be covered. True or False

Answer 12

True

Question 13

for an enterally fed home patient, a pump will be covered if

Answer 13

intolerance to bolus or gravity feeding is demonstrated

Question 14

Third Party insurance payers are the ____ likely to pay for EN formulas because they equate to the cost of a grocery bill

Answer 14

third party

Question 15

the 3 most important monitoring for HEN patients who are stable are

Answer 15

weight, I/O and bowel function

Question 16

if a PEG tube dislodges after the tract matures (>6 weeks) a replacement tube can be

Answer 16

reinserted and surgery is not required

Question 17

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

Answer 17

12

Question 18

what is the best way to ensure the patient is performing proper tube feeding technique

Answer 18

return demonstration

Question 19

To ensure the best adherence to feeding and improved psychosocial health of a tube fed patient their tube feeding schedule should be

Answer 19

integrated into the patient/family’s way of living and should simulate normal meal times

Question 20

in a stable home EN patient, it would be most appropriate to routinely monitor

Answer 20

weight, intake/output, bowel fx

Question 21

enteral feeding should be incorporated into the patient’s/families

Answer 21

lifestyle, mimic normal meal times

Question 22

what is encouraged of family members of an enterally fed patient at home

Answer 22

participation, dinner table socializing

Question 23

a home tube fed patient’s administration schedule should mimic

Answer 23

normal meal times

Question 24

patient education materials should be at the ___ to ____ grade level

Answer 24

5th to 6th grade level

Question 25

the best way to to know the patient/family's understanding of EN delivery is

Answer 25

return demonstration/ teach back

Question 26

an active process where the patient can demonstrate themselves and verbalize the process is called

Answer 26

teach back/ return demonstration

Question 27

Teach Back/Return demonstration helps the patient/family get accurate _______, verify ______ and reinforce new home care ________

Answer 27

information understanding skills

Question 28

the maximum hang time for an open enteral system IN THE HOME SETTING is

Answer 28

12 hours

Question 29

the maximum hang time for a closed system in the HOME setting is

Answer 29

24-48 hours

Question 30

the best way to care for the skin around a feeding tube is

Answer 30

mild soap and water, rinse and keep dry thoroughly, clean under the external bolster

Question 31

when are dressings recommended for PEG tubes

Answer 31

only if there is drainage

Question 32

the home care improvement plan for an enterally fed tube feeding patient measures ________ in the home tube feeding setting

Answer 32

outcomes

Question 33

what NEEDS to be included in the home care improvement plan for home enterally fed patients

Answer 33

1. hospital re admits 2. complications 3. patient/family satisfaction 4. problem reporting/resolution

Question 34

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

Answer 34

1. permit the food to reach the small bowel 2. digestion/absorption of a PO diet 3. test of performance documented by MD 4. statement of permanence (90 days) 5. statement of needing to maintain weight/strength not possible by taking in oral nutrition supplements 6. serum albumin <3.4 g/dL , fecal fat test 7. weight loss >10% >/= 3 months

Question 35

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_____

Answer 35

1. name of the formula 2. total daily volume needed 3. route of administration 4. care of the enteral access device 5. infection prevention 6. run out of supplies 7. storage

Question 36

the most common complication associated with PEG tube placement is ____ which can occur within days to months

Answer 36

peristomal infection

Question 37

examples of Medicare coverage part B conditions

Answer 37

obstruction 2/2 head/neck cancer motility disorders severe dysphagia

Question 38

which conditions are not covered by medicare for home EN

Answer 38

anorexia, malnutrition, nausea

Question 39

Medicare reimbursement for nutrition education by an RD is only covered for

Answer 39

diabetes renal disease (pre dialysis) kidney transplant

Question 40

managed care / private insurance companies usually use ______ criteria for HPN coverage

Answer 40

medicare criteria

Question 41

managed care/private insurance companies usually require _________ and medical _____ and sole source of ______ in order to cover EN

Answer 41

pre authorization medical necessity sole source of nutrition

Question 42

how often initially should electrolytes, glucose, BUN, Cr, Mag, Phos be monitored

Answer 42

weekly for 4 weeks or until clinically stable

Question 43

what type of venous access devices are indicated for home PN use

Answer 43

PICC lines (Hickman) Implanted Ports Tunneled CVCs

Question 44

a permanent ____ must be placed before discharging home with HPN

Answer 44

venous access device (central)

Question 45

upon initiation of home PN, initial lab data should be obtained when

Answer 45

prior to starting home PN

Question 46

the patient/training policies for home PN should address

Answer 46

education training evaluation of the patient/caregiver competency

Question 47

home infusion companies are responsible for the delivery of

Answer 47

1. nutrition products 2. supplies 3. nursing care 4. formula delivery 5. equipment delivery

Question 48

assessing of micronutrient status in HPN patients requires thorough ______

Answer 48

symptom observation

Question 49

copper deficiency masks _____deficiency making it difficult to assess home PN patients

Answer 49

B12

Question 50

Hypermagnesemia results from ______ in HPN patients

Answer 50

commercial trace element preparation

Question 51

manganese is almost fully excreted by the ________

Answer 51

hepatobiliary system (bile)

Question 52

try to decrease the dose of manganese in patients on HPN with

Answer 52

hepatobiliary disease or liver disease

Question 53

who are at risk for a manganese toxicity

Answer 53

long term PN over 30 days with obstruction of the biliary duct

Question 54

when there is a toxicity of manganese with inability to excrete it through the bile, it can deposit in the ______ especially with IV manganese

Answer 54

brain

Question 55

what is the BEST way to detect manganese levels

Answer 55

whole blood manganese

Question 56

what is the best indicator for chromium deficiency

Answer 56

there is NO known reliable indicator of chromium status

Question 57

what are the roles of chromium

Answer 57

1. potentiates the action of insulin | 2. plays a role in glucose, protein and lipid metabolism

Question 58

which populations are at risk for chromium deficiency

Answer 58

1. pregnancy | 2. Type 2 DM

Question 59

if a patient is hyperglycemic, give ______ supplementation and see if the blood glucose resolves

Answer 59

chromium

Question 60

what are some causes of zinc deficiency

Answer 60

inadequate intake, decreased absorption, increased losses, increased demand

Question 61

primary symptoms of zinc deficiency

Answer 61

loss of taste, altered smell, rash, alopecia, gonadal hypofunction, night blindness

Question 62

every HPN patient should get ____ daily unless there is a toxicity / potential for toxicity or national shortage

Answer 62

micronutrients

Question 63

whenever a patient has a nutrient omitted what should be done

Answer 63

monitor for deficiency or toxicity that can develop over time

Question 64

are lab values always the best indicators for normal micronutrient status

Answer 64

NO

Question 65

normal lab values of micronutrients can give a false ______

Answer 65

sense of security

Question 66

failure to monitor which long term micronutrient can result in toxicities of these micronutrients in PN: zinc, manganese, folate or molybdenum

Answer 66

manganese

Question 67

hypermanganesemia can occur in all ____ patients regardless of liver function

Answer 67

long term PN patients

Question 68

PN contains these potential toxic elements from an ASPEN 2009 review

Answer 68

manganese, copper, chromium

Question 69

in the 2012 ASPEN recommendations, there was a recommended decrease of these trace elements

Answer 69

manganese and copper

Question 70

symptoms of manganese toxicity

Answer 70

headache, Parkinson's like abnormalities

Question 71

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

Answer 71

1. the medical record must document failure of EN feeding tube or explain why it is not an option 2. it is critical to document a non functional GI tract

Question 72

diagnosis of a SBO alone is _____ qualifying for HPN

Answer 72

Not

Question 73

Large volume, small volume, pharmacy bulk PN components must be labeled with the amount of ______ anticipated to be in the product when the product _________

Answer 73

aluminum, expires

Question 74

the amount of aluminum on PN labels are about ____________ than what is actually in the PN bag of an individual patient

Answer 74

10 times more

Question 75

pharmacies are not require to list _____ content of each individual patient's PN bag

Answer 75

aluminum

Question 76

symptoms of aluminum toxicity

Answer 76

neurological, hepatic, hematologic, skeletal muscle | Sx are non specific, non sensitive, can include some metabolic bone disease but is not the primary symptom

Question 77

the most practical way to manage micronutrients in long term PN patients is to

Answer 77

perform micronutrient assessment every 6 months including nutrient intake assessment, assessment for potential losses, medications/surgical history and a nutrition focused physical exam

Question 78

what are the causes of nausea and vomiting in long term EN patients

Answer 78

rapid EN infusion, gastric outlet obstruction from tube migration, excessive feeding volume, gastroparesis

Question 79

how is nausea and vomiting prevented in home EN patients

Answer 79

1. decrease TF rate/volume of an EN infusion of N/V occurs

Question 80

many third party payors (insurance companies) equate the cost of EN formulas to the cost of _____ and DON'T cover the expense

Answer 80

groceries

Question 81

if a patient cannot afford their formula, what are their options

Answer 81

1. work with an RD to find an alternative | 2. there are non profit/indigent care programs to help

Question 82

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.

Answer 82

Medicare Part B 20% Supplemental insurance

Question 83

Home blenderized EN formulations should be discarded after _____ hours at home. Their hang time should be ____ hours.

Answer 83

Discard after 24 hours | hang time 4 hours

Question 84

which non profit organization is a great resource for home PN/EN patients

Answer 84

Association of GI motility Disorders

Question 85

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?

Answer 85

inadequate flushing