Home Nutrition Support Flashcards
1
Q
A
2
Q
What type of (nutrition related) supplies are generally covered by insurance?
A
Enteral nutrition administration supplies (i.e., tubing, syringes, bags, etc.)
Coverage is contingent upon meeting criteria for reimbursement for enteral nutrition services.
3
Q
Under what condition are feeding pumps covered?
A
If the patient cannot tolerate gravity feedings or they are contraindicated
Feeding pumps are specifically for patients who cannot use standard feeding methods.
4
Q
What type of formulas are typically considered appropriate for most patients?
A
Standard, polymeric formulas
These formulas are designed for general use in enteral nutrition.
5
Q
Why would a payor not reimburse tube feed formula? m
A
Some payors consider enteral formula equivalent to the cost of food, if a patient were eating orally, and do not reimburse for formula.
This can affect reimbursement policies regarding enteral nutrition.
6
Q
Is nutrition supplementation generally covered under Medicare or private insurance benefits?
A
No
Nutrition supplementation is not typically included in Medicare or private insurance benefits.
7
Q
Anemia associated with copper deficiency may be ___cytic, ___cytic, or ___cytic.
A
Normocytic, macrocytic, or microcytic
8
Q
What are the most common manifestations of copper deficiency?
A
- Anemia
- Leukopenia (primarily neutropenia)
- Foot numbness
- Gait difficulty
Hematological and neurological abnormalities often coexist but may occur independently.
9
Q
What are the sign/symptoms associated with copper deficiency?
A
- Dysfunction of the spinal cord (which may result in paresthesia/tingling and numbness of the lower extremities)
- Sensory ataxia (balance)
- Occasionally a spastic gait
10
Q
The neurological presentations of copper deficiency are also associated with vitamin ___ deficiency.
A
B12
11
Q
What is the “Oley Foundation”
A
A national, independent, non-profit organization that strives to enrich the lives of those living with home intravenous nutrition (parenteral) and tube feeding (enteral) through education, advocacy, and networking.
12
Q
What should be included in the home care provider’s performance improvement and outcome measurement activities?
A
Data collection on:
- Mortality
- Hospital readmission
- Complications
- Patient/family satisfaction
- Problem reporting and resolution
These metrics help assess the effectiveness and safety of nutrition support.
13
Q
What labs should be monitored for home TPN patients?
A
-BMP
-LFTs
-CBC
-Mg
-Pho
14
Q
Home TPN patients should initially have laboratory tests should be done on a ___ basis for ___ weeks or until values are stable.
A
-Weekly
-4 weeks
15
Q
Once home TPN patients are deemed “stable”, how often should they have labs take?
A
Once a month (or less, depending on the patient)
16
Q
Home TPN patients should have a follow up ____ or ____ unless there’s a change in clinical status (where they would require more frequent check ons)
A
-Monthly
-Bi-monthly
17
Q
When possible in the home setting, the administration schedule should be structured to simulate what?
A
Normal meal times
18
Q
Separation of the patient from the family during meal times may have a ____ impact on the family structure
A
Negative
19
Q
Is it required for home PN patients to have a cell phone?
A
Yes. They require a home/cellular telephone (or other means of contact) in the event of a medical emergency.
20
Q
What two items are recommended for home PN patients to have - if they have frequent interruptions in electrical service?
A
1.Back-up battery-powered infusion pump
2. A back-up electrical generator may be needed.
21
Q
True or false: a dedicated infusion area and refrigerator are required for home PN
A
False. While preferred, an isolated infusion area and dedicated refrigerator are not required.
22
Q
True or false: an area that can be used for home PN supply storage is required
A
TRUE. An area that can be used for supply storage is required.
23
Q
What 5 things are required for the home (for home PN patients)?
A
- Telephone
- An area for supply storage
- Sanitary water
- Electricity
- Refrigeration
24
Q
Is it required that patients on home PN have a caregiver?
A
No. Labs may be obtained by a homecare nurse. If the assessment is made that the patient has the ability to be educated regarding the prescribed therapy, there is no need for a caregiver to be available to the patient at home.
25
Manufacturers of large volume, small volume, and pharmacy bulk packages of components for PN must label each with the amount of aluminum anticipated to be in the product when the product ___.
Expires
26
How much more aluminum is indicated on the label compared to what was actually measured in a PN bag?
Approximately 10 times more
27
Are pharmacies required to list the aluminum content on each patient's PN bag?
No
28
What are the clinical manifestations of aluminum toxicity?
Neurological, hepatic, hematologic, and skeletal
29
Does aluminum toxicity contribute to metabolic bone disease?
Yes. However, the etiology of parenteral nutrition-associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors.
30
What resources are provided by the Oley Foundation?
Some of the resources available are a toll-free hotline, video library, equipment and formula exchange, bimonthly newsletters, My HPN online education modules, and an annual summer conference.
31
Medicare reimburses nutrition counseling for what 3 disease?
1. Diabetes
2. Non-dialysis kidney disease
3. Those who have had a kidney transplant within the past 36 months
32
What factors help patients adjust to home PN?
Ability to maintain stability in their personal lives (jobs, family, finances)
33
A source of concern for home PN patients is the ___ effect of the catheter
Cosmetic
34
Why do patients with chronic bowel disease cope with home PN better than other patients?
They often see relief from frequent hospitalizations and abdominal discomfort.
35
Home PN is often cycled at night. How might patient's day be affected?
The inability to eat can significantly affect social quality of life
36
What does Medicare cover regarding tube feeding expenses?
When tube feeds meet 100% of nutrition needs
## Footnote
Medicare will not pay for supplemental tube feeding or oral nutrition supplements.
37
The nutrition prescription for EN must reflect ___-___ kcals/kg for medicare coverage
20-35 kcals/kg.
## Footnote
This reflects the caloric intake required for enteral nutrition.
38
What is a common requirement for non-government insurance reimbursement for home enteral nutrition?
It must be medically necessary and the sole source of nutrition.
## Footnote
This is similar to Medicare's requirements.
39
Complications that can be easily identified by patients or caregivers should be reviewed during ___-___ teaching.
Post-discharge
40
Why is iron not included in PN formulations?
To avoid potential contribution to microbial growth and damaging oxidative reactions.
41
When should parenteral iron be considered?
In conditions of iron deficiency when the oral route is ineffective or not tolerated.
42
What symptoms may patients with iron deficiency anemia present with?
1. Fatigue
2. Headache
3. Pallor (pale skin)
4. Reduced work performance
5. Impaired behavioral and intellectual performance
6. Impaired ability to maintain body temperature
43
Is iron compatible with a 3-in-1 PN solution?
No, iron is not compatible with a 3-in-1 PN solution.
44
In which type of PN solution can iron be added?
A 2-in-1 PN solution.
45
What is the preferable form of iron to add to PN?
Iron dextran.
46
What must be done before adding iron dextran to PN?
The patient must be given a test dose to evaluate tolerance and avoid anaphylactic reactions.
47
How often should serum iron and ferritin levels be monitored if a repletion dose is added to the PN solution?
Routine monitoring should occur every 1 to 3 months
48
What is a potential risk of adding iron to PN solutions?
Iron overload
49
The most practical approach to managing micronutrients and monitoring micronutrient status in long-term PN patients is to perform a micronutrient assessment every ___ months
6
50
What are the components of a micronutrient assessment?
1. Review of nutrient intake
2. Potential nutrient losses
3. Medications
4. Medical/surgical history
5. NFPE
51
Every patient should receive micronutrients daily unless there is a potential or identified ___ ___, or adjust accordingly if there is a ___ ___e of product.
1. Nutrient toxicity
2. National shortage
52
Whenever a nutrient is omitted or added to standard micronutrient recommendations, the patient should be monitored for a potential ___ or ___ that could develop over time.
Deficiency or toxicity
53
What limitations exist with monitoring micronutrient levels in PN patients?
Laboratory values are not always reliable indicators. Normal levels can give a false sense of security when in fact the patient is deficient or toxic.
54
What are the potential causes of zinc deficiency?
Inadequate intake, reduced absorption, increased losses, increased demand
## Footnote
These factors contribute to the body's insufficient zinc levels.
55
List 7 symptoms of severe zinc deficiency.
1. Loss of taste sensation
2. Altered smell sensation
3. Skin rash
4. Growth failure
5. Alopecia
6. Decreased muscle work capacity
7. Gonadal hypofunction (lower testosterone and fertility)
## Footnote
These symptoms indicate a significant lack of zinc in the body.
56
How does zinc deficiency affect vitamin A?
It may lead to decreased vitamin A release from the liver, contributing to nighttime blindness
## Footnote
This connection highlights the importance of zinc for proper vitamin A metabolism.
57
What roles does zinc play in the body?
Needed for growth and tissue maintenance
## Footnote
Zinc is crucial for various physiological functions.
58
Anemia is not associated with zinc deficiency, but could be a symptom of zinc ___ if that leads to ____ deficiency.
-Toxicity
-Copper
## Footnote
This occurs if zinc toxicity results in copper deficiency.
59
In what cases would gravity feeding be contraindicated? Particularly for Medicare coverage.
- Reflux
- Aspiration
- Dumping syndrome
- Glycemic control
- Circulatory overload
- Slow infusion rate
- Jejunal feeding
60
Name the responsibilities of the home infusion company/provider
- Delivery of nutritional products
- Appropriate supplies for the delivery of nutrition
- Nursing care required to educate about and monitor the prescribed therapy
61
Home enteral nutrition is a covered Medicare Part B benefit for a patient who has a permanent condition or disorder (defined as >___days) that impairs food from reaching the small bowel or disease of the small bowel that impairs digestion and absorption of adequate nutrition.
90
## Footnote
Permanent condition is defined as lasting more than 90 days.
62
The beneficiary (patient) must require tube feeding to provide adequate nutrients to maintain ___ and ___ commensurate to their overall health status.
Weight and strength
63
What are potential causes of dysphagia that qualify for home enteral nutrition?
1. Anatomical causes (e.g. obstruction due to head and neck cancer or reconstructive surgery)
2. Motility disorders (e.g. severe dysphagia following a stroke)
64
Is enteral nutrition covered for patients with a functioning gastrointestinal tract?
No, it is not covered for patients whose need for enteral nutrition is due to reasons such as anorexia, malnutrition, or dementia.
65
What are the reasons home enteral nutrition is not recommended for individuals with advanced dementia?
1. It does not improve prognosis
2. It does not reduce symptoms
3. It does not improve quality of life
4. It offers no additional benefit over hand feeding
66
Laboratory data should be obtained ____ to home PN initiation.
Prior
67
The diagnosis of ___ ___ ___ is critical to ensure home PN coverage.
Nonfunctional gastrointestinal tract
68
Does a diagnosis of pSBO qualify a patient for home PN?
The diagnosis of partial small bowel obstruction alone will not qualify a person for HPN under present Medicare guidelines.
69
For home PN coverage, the chart must document what about EN?
That EN has been considered, tried and failed, or may exacerbate GI dysfunction
70
What are the two general coverage requirements for home PN according to CMS?
1. Disease of the small intestine and/or exocrine glands that significantly impairs nutrient absorption
2. Motility disorders of the GI tract which results in severe nutrient malabsorption
## Footnote
These determinations are essential for qualifying for HPN coverage.
71
What additional documentation is required for CMS home PN coverage?
1. Patient diagnosis
2. Duration of the patient's condition
3. Clinical course
4. Prognosis
5. Nature and extent of functional limitations
6. Other therapeutic interventions and results
7. Past experience with related items
## Footnote
Comprehensive documentation helps in assessing the need for HPN.
72
What does CMS require regarding the test of permanence for HPN?
Must indicate in the medical record that they will require HPN for a long and indefinite need, generally believed to be at least 3 months' duration
## Footnote
This requirement ensures that HPN is necessary for ongoing treatment.
73
True or False: CMS provides coverage for supplemental HPN.
False
## Footnote
CMS generally does not cover supplemental HPN.
74
What does 'clinical course' refer to in the context of HPN documentation?
The worsening or improvement of the patient's condition over time
## Footnote
Understanding the clinical course aids in treatment planning.
75
What 3 micronutrients in PN are most "risky" for toxicity?
1. Manganese
2. Copper
3. Chromium
76
In 2012, ASPEN recommended decreasing ___ and ___ doses in the PN to prevent toxicity
Manganese and copper
77
What are symptoms of manganese toxicity?
Headache and Parkinson-like abnormalities.
78
The etiology of metabolic bone disease is multi-factorial. Name a few potential etiologies:
1. Long term PN
2. Pre-existing disease
3. Malabsorption
4. Metabolic acidosis
5. Steroid therapy
6. Inactivity
7. Mineral deficiencies (calcium, phosphorus, magnesium)
8. Vitamin D deficiency or excess.
79
What should be monitoring annually to assess for metabolic bone disease?
Bone mineral testing (DXA) should be done annually.
80
How often should a DEXA be performed for home PN patients?
Once per year
81
What nutrition intervention should come next for a patient with gastroparesis who cannot tolerate a gastroparesis diet?
Small bowel EN feeding to bypass the stomach.
82
Will medicare approved home PN for fat malabsorption?
Yes. Medicare will approve HPN if there is evidence of fat malabsorption.
83
What are some causes of nausea and vomiting in enterally fed patients?
Causes include:
- Too rapid rate of bolus infusion
- Gastric outlet obstruction
- Excessive feeding volume
- Gastroparesis
- Gastric irritation or atony/stasis
- Distal obstruction
- Anxiety
- Other diseases
- Medication
84
How can nausea and vomiting in enterally fed patients be prevented or resolved?
By decreasing the rate or volume of enteral infusion
85
True or False: Frequent use of sorbitol-containing medications is a common cause of nausea and vomiting in tube feeding.
False
86
What is one common cause of tube feeding-associated diarrhea?
Frequent use of sorbitol-containing medications
87
Chromium potentiates the action of ___ and has a role in ___, ___, and ___ metabolism.
- Insulin
- Glucose
- Protein
- Lipid
## Footnote
Chromium is essential for the proper functioning of insulin, which regulates blood sugar levels.
88
What conditions can lead to increased urinary excretion of chromium?
Pregnancy and type 2 diabetes can potentially lead to increased urinary excretion of chromium.
## Footnote
These conditions may affect chromium levels in the body.
89
How can chromium deficiency be empirically assessed?
If deficiency is suspected, treating hyperglycemic patients with chromium supplementation and observing for resolution of symptoms empirically is the best way to determine if the patient was chromium deficient.
## Footnote
This method relies on the clinical response to supplementation as a diagnostic tool.
90
Are there known reliable indicators of chromium status?
No. There are no known reliable indicators of chromium status.
## Footnote
This makes it challenging to assess chromium levels in individuals.
91
What is a challenge in detecting chromium levels in the body?
Levels in the blood are present in extremely low concentration making detection (with a lab value) difficult.
## Footnote
Due to this low concentration, standard testing methods may not be effective.
92
What should discharge instructions for a patient/caregiver include?
1. The name of the formula
2. Total daily volume
3. Route of administration
4. Timing/duration of administration,
5. Care of the enteral access device
6. Product hang-time
7. Stability at room temperature
8. Inspection of enteral products for defects and expiration dates
9. Infection prevention and control
10. Action for late or missed administration of enteral nutrition
11. Proper storage of opened and unused enteral products
93
What information should be provided regarding the home care company upon discharge?
Contact information for the home care company.
94
Is it necessary for the patient to know the protein and calorie provision?
No, it is not necessary for the patient to know this information.
95
The use of home-prepared or blenderized EN formulations requires additional attention to ___ content, safe food ___ and ___ practices.
- Content
- Handling
- Storage
96
Blenderized formulas should be discarded after ___ hours.
24
97
Skin around a feeding tube site should be cleaned with ___ ___ and ___, rinsing and drying thoroughly.
Mild soap and water
98
How should patients clean under the bolsters of their feeding tube?
Patients should be taught to clean carefully under external bolsters to remove debris and check for excessive pressure.
99
Is routine use of antibiotic ointments around feeding tube sites advised?
No
100
Are dressings at the tube insertion site recommended?
No. Not necessary unless there is drainage.
101
Government programs (i.e., Medicare and Medicaid) have strict coverage criteria for home PN/EN. What do they require to determine eligibility?
Detailed history, tests and nutritional data
102
Coverage policies and reimbursement for HEN and HPN also vary with private payers and managed care organizations and frequently require pre____ or pre___
Preauthorization or precertification
103
Most insurance companies require that the PN/EN be medically ___ and the ___ ___ of nutrition.
-Necessary
-Sole source
104
Many insurance policies establish their own criteria for EN and PN, while others follow the guidelines for coverage set forth by ___.
Medicare
105
Hypermanganesemia has been reported in >___% of home PN patients
50%
## Footnote
Accompanied by clinically significant cerebral and hepatic complications
106
What accompanies hypermagnesemia?
Clinically significant cerebral edema and hepatic complications
107
How is manganese primarily excreted from the body?
Via the hepatobiliary system
108
Reductions in ___ dosing should be considered in patients with cholestatic liver disease.
Manganese
109
What may need to be removed from the PN solution in patients receiving long-term PN?
Supplemental manganese
110
At what daily intravenous dose can brain deposition of manganese occur?
1.1 mg
111
What imaging modality can detect manganese toxicity?
Magnetic resonance imaging (MRI). However, this is expensive and not preferred.
112
What is the preferred method for monitoring manganese status?
Taking a serum lab level
113
What does it mean if educational materials are in "plain language"
A communication is in plain language if its wording, structure, and design are so clear that the intended audience can easily find what they need, understand what they find, and use that information.
114
What are the two criteria a beneficiary must meet for Medicare coverage under HEN?
1) A permanent nonfunction or disease of the structures that normally permit food to reach the small bowel
2) A disease of the small bowel that impairs digestion and absorption of an oral diet
115
What does 'permanence' mean in the context of Medicare coverage for HEN?
'Permanence' means that the condition is of indefinite duration, defined as 90 days or greater
116
Open system enteral feeding containers should have a hang time of no more than ___ hrs at home and ___ hrs in the hospital.
-12
-8
117
Open system enteral feeding containers are more likely to be exposed to ___.
Contaminants
118
Closed system enteral feeding containers have a longer hang time of up to ___-___ hrs.
24-48
119
___ around the insertion site is a relatively common post-procedural complication reported in up to 30% of tubes placed.
Infection
120
___ ___ ___ is a result of erosion of the internal bolster into the gastric mucosa and occurs in 0.3-2.4% of patients.
Buried bumper syndrome
121
What causes ulceration of the gastric mucosa in patients with a PEG?
Caused by excessive tension between the external and internal bolster which leads to erosion and bleeding.
This occurs in only 0.3-2.5% of cases.
122
Colocutaneous fistulas occur when the colon is inadvertently ___ during placement. It is extremely rare, occurring in only 0-0.27% of cases.
Punctured
123
EN and PN are primarily covered under the “___ ___” benefit under the Medicare Part B program
Prosthetic device
124
The "prosthetic device" benefit requires a permanent ___ of a body organ
Dysfunction
125
What must be demonstrated for therapy to be considered 'reasonable and necessary' under Medicare?
Diagnosis or treatment of illness or injury
or
To improve the functioning of a malformed body part
126
What is required regarding nutrients for EN or PN reimbursement?
Provision of sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status.
127
Home PN patients with significant ___ dysfunction and ___ deficiency are at risk for aluminum toxicity due to impaired excretion or excessive exposure that aluminum accumulation occurs
-Renal
-Iron
## Footnote
Impaired excretion or excessive exposure can lead to aluminum accumulation.
128
What organ is primarily responsible for unbound aluminum excretion?
The kidneys
## Footnote
The kidneys play a crucial role in the elimination of unbound aluminum from the body.
129
What is the primary protein that binds to aluminum in the bloodstream?
Transferrin
## Footnote
The majority of aluminum in the bloodstream is bound to proteins, making it unable to be excreted.
130
Fill in the blank: Patients on long-term PN support still have a risk for _______ toxicity due to many components of PN having an affinity for this element.
Aluminum
## Footnote
This indicates that careful monitoring is necessary for patients receiving long-term parenteral nutrition.
131
Why is it recommended to use the largest bore feeding tube possible?
Large bore tubes are less likely to clog by either medications or viscous formula.
## Footnote
Large bore tubes are less likely to clog by either medications or viscous formula.
132
When should feeding tubes be flushed to maintain patency?
Immediately before and after intermittent feedings or at standard intervals with continuous feeding regimens.
Also, before and after medications.
## Footnote
Flushing is also necessary before and after medication administration.
133
What is the effect of limiting gastric residual checks?
It may prevent the precipitation of protein in the enteral formula within the lumen of the tube due to acidic gastric contents.
GRV checks should be limited.
## Footnote
This is important to minimize tube clogging.
134
What is the preferred method to minimize the risk of enteral feeding tube occlusions?
Prevention through consistent and scheduled flushing of all tubes.
## Footnote
Best practice is to flush feeding tubes regularly.
135
What type of solution is found to be most effective for tube flushing?
Water.
## Footnote
Water is accessible, cost-effective, and has not been surpassed by any other solution.
136
What types of water can be used for tube flushing?
Drinking water or sterile water.
## Footnote
Both options are acceptable for flushing feeding tubes.
137
Which form of medication is less likely to occlude feeding tubes?
Medications in liquid form.
## Footnote
Liquid medications should be used if available, as crushed pills can contribute to clogging.
138
How should medications be administered through feeding tubes?
Each medication should be given separately with a water flush before and after each administration.
## Footnote
This practice helps maintain tube patency.
139
After initial certification for parenteral nutrition is obtained, recertification is required after ___ months of therapy.
6
140
The recertification process for home PN is used to document the patient's ___ ___ for therapy
Continued need
141
One of the most effective ways to improve understanding of discharge teaching while simultaneously addressing health literacy is the “___-___” process.
Teach-back
142
The teach-back process allows the educator to verify ___, to correct inaccurate information, and to ___ new home care skills.
-Understanding
-Reinforce
143
What is the effect of a 70% ethanol lock (ELT) solution on VADs?
It removes the luminal biofilm inside VADs where microorganisms are harbored
## Footnote
This action can help prevent central line associated bloodstream infections.
144
What is a consequence of microorganisms detaching from the biofilm in VADs?
They can seed the bloodstream, causing central line associated bloodstream infection
## Footnote
This highlights the importance of biofilm management in preventing infections.
145
What should be considered to prevent recurrent infections in VADs?
Ethanol lock (ELT) solution
## Footnote
ELT is being studied for its effectiveness as standard care.
146
What are some potential risks associated with using ELT?
Increased breakage and thrombosis, and weakened VADs made from polyurethane
## Footnote
These risks must be weighed against the benefits of using ELT.
147
What is a compatibility issue with ethanol in medical use?
Ethanol is incompatible with heparin
## Footnote
This incompatibility can affect treatment protocols involving anticoagulation.
148
Parenteral nutrition associated cholestasis is a condition of impaired secretion of ___ or frank ___ obstruction that occurs predominately in children, but it may also occur in adult patients receiving long-term PN
-Bile
-Biliary
149
What are labs might be elevated in PN associated cholestasis?
- Alk phosphatase
- Gamma-glutamyl transpeptidase
- Conjugated (direct) bilirubin
150
What is consider the "prime" indicator of PN associated cholestasis?
Elevated serum conjugated bilirubin (i.e., >2 mg/dL)
151
What are the main causes of liver complications in PN?
Excessive energy intake from dextrose and/or intravenous fat emulsion
152
What trace elements may be elevated in cholestasis?
Manganese and copper
153
Why might manganese and copper be elevated in cholestasis?
They are excreted via the biliary tract
154
Should all trace elements be removed if manganese and copper are elevated?
No. Although the dose of manganese and copper may need to be reduced or eliminated, the removal of all trace elements is not warranted.
155
After other causes of liver dysfunction have been addressed, ___ may be added to PN if a deficiency exists.
Carnitine
156
True or false: The role of carnitine in the prevention of PNAC in adults has not been established.
True
157
___ deficiency also may be related to the development of PN-associated liver dysfunction, but there is no commercially available injectable form and benefits of supplementation have not proven.
Choline
158
Why is the education, training and evaluation of patient and caregiver competency so important?
It promotes patient and provider independence
