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Home Nutrition Support Flashcards

1
Q

What is considered as short term feeding in home NS? Long-term feeding?

A

Short term: < 2 years

Long term: > 2 years

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2
Q

Name examples of conditions that require short term home NS.

A
  • Cancer patients undergoing chemotherapy +/- radiotherapy tx
    Usually present dysphagia or odynophagia secondary to cancer tx which will resolve with time
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3
Q

Name examples of conditions that require long-term home NS

A
  • Cancer patients who have permanent dysphagia 2/2 cancer tx or surgery (e.g. partial or total removal of esophagus or stomach)
  • Degenerative diseases (Parkinson’s, SLA, MS, PSP)
  • Dementia (alzheimer’s, others)
  • Trisomy
  • Cerebral palsy
  • Oculopharyngeal muscular dystrophy
  • Stroke
  • Some cancer patients
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4
Q

Which pump is provided for short term nutrition support by the Ministerial Enteral Nutrition Program (MENP)?

A

The feeding pump provided is the Connect pump

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5
Q

Which pump is provided for long term nutrition support by the Ministerial Enteral Nutrition Program (MENP)?

A

Kids: Joey pump
Adults: ePump

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6
Q

What are the 4 MNEP forms for professionals?

A

 Practical guide for Short term feeding
 Practical guide for Long term feeding
 Practical guide
 Request form

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7
Q

What are the 2 MNEP forms for patients?

A

 Practical guide for Short term feeding

 Practical guide for Long term feeding

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8
Q

Who usually fills the request form?

A

Hospital dietitian

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9
Q

What does the practical guide for clinicians include?

A
  • Explains how to fill the request form
  • Explains the quotas of material
  • Examples of material request forms
  • Explains how it works for patient with private insurance
  • Cleaning process
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10
Q

What is the RAMQ form to fill our? Who usually fills it?

A

Exception medication form, usually filled by hospital
Dietitians might need to fill this form if there is a change in the EN solution or if the solution was only authorized for a certain period of time (e.g. short-term patients)

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11
Q

What does private insurance usually cover? What does government insurance usually cover?

A

Private:
- Enteral solution
- PARTIALLY: Feeding material
The portion of the material that is not covered by private insurance can be claimed to the MENP after

If patient is covered by the government: everything is covered (material, formula etc.)

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12
Q

Which part of the population is usually more on open systems? Why?

A

Kids, they need less kcals and protein

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13
Q

Name 1 benefit of open systems.

A

Open system less expensive than closed system; MENP considers that everybody should be on an open system as the material (feeding bag) is less expensive than for closed system (feeding tube)

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14
Q

Name 3 drawbacks of open systems

A

– More risks of infection/contamination
–> Need to wash hands and wash container before you open it; More manipulation involved
– Bag needs to be washed often
Intermittent feeding: Bag has to be rinsed after each feeding and washed once a day
Continuous feeding: Bag has to be washed after each feeding

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15
Q

Which part of the population is usually more on closed systems? Why?

A

Adults (after justifications for MNEP to accept)

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16
Q

Name 2 benefits of closed systems

A

– Less risks of infection/contamination

– Bag can be in suspension for up to 48 hours

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17
Q

Who should be using NG and NJ tubes at home?

A

Kids

Short-term feeding (4-6 weeks)

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18
Q

Name 4 drawbacks of NG/NJ tubes

A

More at risk of nasal infections, uncomfortable, visible, can move/be removed easily

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19
Q

How can we make sure a NG/NJ tube is still in place?

A

Have to measure the length of the tube that is coming out of the nose and/or use a black marker to identify the exit point of the tube. This will allow you and/or the nurses to see if the tube is still in place.

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20
Q

How to know if a tube is well placed in the stomach?

A

Insert air in it while you listen to the stomach noises. If you hear the air come in, the tube is in the right place and you can start the feeding, this should be done at the hospital when they place the tube but it can also be done at home when in doubt

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21
Q

How to know if a tube is well placed in the jejunum?

A

Via radiology

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22
Q

Who places NG/NJ tubes?

A

The nurse

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23
Q

What type of feeding should we give patients on these tubes?

A

Continuous feedings only as these tubes are really narrow (12 Fr, 14 Fr)

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24
Q

What are the 3 types of PEG tubes? Which is the most common?

A
  1. Balloor tube (most common)
    Ponsky non-balloon tube
  2. Gastric button
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25
How much time do we have to put a balloon tube back in place in cases of pulling? Ponsky non-balloon tubes?
Balloon tubes: 2h | Ponsky: Cannot put it back except if we have an obturator in hand and nurse comfortable to do it.
26
Where is usually placed a PEG on the belly?
Right side
27
How often does a balloon tube need to be checked?
The balloon PEG has to be verified once a week (q 2-3 days ASPEN = unrealistic) by a nurse to make sure that the balloon is still inflated at its maximal capacity. If the balloon deflates, it has to be inflated again to see if it’s leaking water. If the balloon is perforated (filled too much, too old or too much acidity), it has to be changed. This could be done by a certified nurse with a PEG of the same or bigger caliber (Fr)
28
How is a Ponsky non-balloon tube inserted?
Use obturator to push on the dome and then remove it to open the dome inside of the stomach
29
Name 1 benefit of ponsky tubes vs balloon tubes
Eliminates the weekly verification and refill of water needed for the balloon tube
30
What is a gastric button made of?
Can be dome but usually balloon filled with water Separate: extension tube
31
Who usually gets those tubes? Why?
Kids: less risk of pulling | Some patients with dementia
32
What is done with the extension after use?
The same extension is use repeatedly so it has to be washed
33
How often is the button changed? By who? What type of feeding does it give?
Parents change the gastric button about once a year | Continuous or intermittent feedings
34
Where are PEG-J tubes usually placed on the belly?
Left side
35
How often are PEG-J tubes used? For which patients?
Not often seen in home care, often more PEG or PEJ Often used with a patient with a PEG has reflux or problems with stomach emptying  might go to PEG-J (although not the best way to prevent aspiration because sphincter is still open)
36
How do we know if the tube is still in place for PEG-J and PEJ?
Have to check how long is coming out, measure it and mark it down with a black marker
37
What types of feedings are used in PEG-J and PEJ?
Continuous only
38
Where are PEJ tubes usually placed on the belly?
Lower left side
39
How are PEJ tubes attached inside the body? Can they be put back in place after pulling?
``` Cannot be put back in place in cases of accidental removal Stopper sometimes (external); suture inside ```
40
What is an advantage of PEJ?
prevent aspiration of the solution (but aspiration may be d/t saliva…)
41
What is a tube adaptor and what is it used for?
o If end of gastrostomy breaks, need to have an adaptor on hand to close the end of the tube
42
What are attachment devices and what are they used for?
o Some tubes have no stoppers – use for those (mostly PEJ) o Use to fix the tube in position on the belly o The tube should not be loose and move in/out of the belly as it could get infected o Very comfortable, no marks on skin. Put around tube an insert tube, close around tube with “tywrap” o More comfortable on the side of the stomach; less inconvenient than in the middle o Horizontal or vertical
43
What are 10cc syringes used for? 60 cc with catheter tip? 60 cc with luer lock?
10cc = used to fill in the balloon with water 60cc w/ catheter tip: medication, bolus feeds and flushing of gastrostomy and nasal tubes 60 cc w/ luer lock: flushes for jejunostomy (no bolus feeds)
44
What does the MENP program give for syringes / week?
2 syringes per week
45
Name 2 tools to crush medications.
Mortier pilon - Practical at home Pill crusher - Makes the nicest power/best and easiest way - Best for people with arthritis, easier to hold and use - Put meds inside and turn cap --> crushes med which falls in the container at the bottom
46
Why are diabetic formulas rarely used?
Because they only contain 1 cal/mL
47
What is the concentration of renal formulas?
1.0 kcal/mL
48
Why is compleat (natural food formula) not used often?
+ thick --> not appropriate for small caliber tubes
49
Name 2 unclogging medications
Cotazym Viokase (+ sodium carbonate)
50
What is the protocol for unclogging formulas?
Mix enzymes with sodium carbonate; in warm water. Let act 20-30 minutes. Pull and push with syringe Cotazym dilué dans une solution de NaHCO3 et à administrer le plus près possible de l’occlusion (par exemple, utiliser un cathéter d’épidurale pour se rapprocher du site). Laisser agir 20-30 minutes.
51
What do you need a pole for in NS?
* Gravity bags | * Feeding pumps
52
For a gravity bag, 1 mL = how many drops?
16 drops
53
Why does one always need a gravity drop?
Always good to have one per patient in case of loss of electricity for a long period of time...
54
What is the company that sells ePumps, Joey pumps and Connect pumps?
Medtronic
55
Why is a joey pump easier for kids?
 For kids, smaller  Can be put in backpack  Can be used in adults with convincing arguments (for special conditions; i.e. very bad arm, hard to open in ePump.)
56
Why is there more risk of infection in feeding bags?
– Has to be rinsed after each use in case of an intermittent feeding – Has to be washed once every day – Has to use the same bag for 3 days
57
What are particularities for closed systems?
* Not provided by the MENP as it cost three times more * You still need to flush with a syringe for the medication * Easy to use: one tube per bag/bottle of feeding for a maximum of 48 hours
58
What to consider for feeding administration?
Patient, home conditions, elimination (bowel movement, urine), type of administration (bolus, intermittent, continuous), schedule, medication
59
What common medication can cause diarrhea?
Prevacid Fastabs (PPI)
60
For which medications does the feeding need to be stopped 1-2 hours before/after? Why? With how much water should we flush?
- Ciproflaxcin - Phenytoin (dilantin) - epilepsy - Warfarin – blood clotting May use at least 60 mL flushes with those meds
61
What is the maximal rate for jejunal feeds?
Jejunum: Max rate 125-130 mL/hr (some up to 140 mL/hr)
62
Why do cancer patients need more fluids?
Cancer patients need a lot of water to wash off the chemical from their body
63
What should we follow up on in patients on home NS?
- Weight (if cant weigh - clothes fit?) - Blood sugar (consider feeding schedule) - GI symptoms (cramps, reflux, diarrhea, constipation) - Bowel movements (normal to be soft bc patient gets liquid food) - Labs 1x/month in CLSC, at least 1x/year --> Most important: Electrolytes, osmolality (or at least Na, urea and glucose so you can calculate it yourself), albumin and proteins, glucose, HbA1c, fat, enzymes
64
What can cause constipation in home NS?
Rx (cancer patients = pain killers), reduced mobility and disease (MS, SLA, PSP, Parkinson)
65
What can cause diarrhea in home NS? What can be done to prevent?
o D° mostly 2° to Rx (liquid Tylenol, Prevacid fastab, laxative) o 1st thing to do in case of D°: hold the laxatives, change liquid Tylenol for pills, reduce feeding rate and maintain hydration
66
How do we calculate blood osmolality?
Osmolarity=(Na+ x 2) + urea + glucose
67
What is the normal osmolarity range?
275 (280) to 295 (300)
68
What blood value is often low in people with jejunostomy? What can be done to fix this? Why does it happen?
if your patient has a jejunal tube the absorption of some nutrient might be affected Jejunostomy = calcium often low since usually absorbed in duodenum Might ask for an IV in some cases
69
What 4 things can be added to feeding? Why would they be added?
``` Protein powder (beneprotein, EZ protein-->easier to dilute) - In case of wounds or if the feeding does not provide enough protein ``` Glucose - In case the feeding does not provide enough calories but has enough fat and protein - In case of hypoglycemia – Bio-K In case of antibiotics --> diarrhea; do not give BioK at the same time as antibiotics or meds - In case of Hx of CD - In case of diarrhea - Has to be given 2-4 hours before or after the antibiotic - Company does not recommend to dilute (but dilute if tube < 8 french) Certo - Usually done to make jam; pectin - To get the stools more consistent in case of diarrhea: add with salt and dilute in water --> flush tube - Do not give in case of CD because we want to get rid of the bacteria - Has to be diluted in water and salt has to be added to help create water absorption - Not recommended in very small tubes
70
What are possible complications of home EN? What to do to help?
- Nausea/vomiting (medication-chemo, feeding rate too high, consider continuous feeding) - Diarrhea/constipation (often d/t medication, adjust hydration, may change solution) - Cramps (constipation? water too cold? reduce feeding and consider medication) - Infection of the site (yellow-white liquid? odor? treat with antibiotic, may have to change tube site) - Tube obstruction (Use unclogging meds/digestine enzymes and sodium carbonate, coke last resort) - Hypoglycemia (15 g CHO, same as oral tx)
71
Which contact informations are important for you and patient on NS? why?
Nestlé or Abbott rep: o If you need to test a new enteral solution; May ask for a week worth of supplies to try a new formula, for example Stomomedical (place where they have some extra tubes and feeding) o To get material or enteral solution (Nestlé) if the patient didn’t receive their order or if they need more material which is not covered by the MENP o Can also provide single items (e.g. a single tube in cases of emergencies) ``` Medtronic rep (company that provides the pumps) o To change the pump o Plan a new training; they do teaching of pumps o Help with pump difficulties ``` MENP o Order material o Question regarding program
72
What will the new authorized acts allow dietitians to do?
``` Prescription o Enteral formulas o Vitamins and minerals o Enteral feeding materials o Pancreatic enzymes solutions *Notice tube insertion is NOT present in the list - dietitians cannot do this in Quebec ``` Proceed to the permanent removal of the enteral feeding o Gastric delivery o Jejunal delivery (still unsure)
73
At what age does the transition from kids to adult solution take place? How do we go about choosing the right one?
Around the age of 12 • Try different products for about 1 week each • Start with an adult product with the same amount of kcal/mL at first and then increase slowly (If they were getting 1 kcal/mL --> try 1 kcal/mL in adult solution as well) • Verify the GI symptoms Will need to fill in a new RAMQ “Authorisation de paiement the medicament d’exception” form and get the doctor to prescribe the new feeding
74
How do we transit from bolus to intermittent feeding? From bolus to continuous?
Intermittent feeding Give the same amount per feeding on a period of 1-2 hours E.g. 500mL x 15min TID --> 500 mL at 500mL/hour Continuous feeding Give the same amount daily on a long period of time (12h +) E.g. 500 mL TID = 1500 mL DIE / 12 hours = 125 mL/h Flushing before and after each feeding + with Rx + PRN
75
How to transit from gravity to pump?
1) MENP if the patient would qualify 2) Pump company for a pump + tubing for a test for about a week 3) Nestlé or Abbott feeding (closed or open system) for a test for about a week Once the test is done and your patient decides on taking the pump, you have to make an official request to PMAE (make sure to have good arguments)
76
How to go from open to closed system?
Same procedure as for bolus to pump o MENP o Company (tubes) o Nestle or Abbott Forms to take care of o New RAMQ form (change in formula container) o New Rx from MD o Advise pharmacy of the change
77
How to transit from open to closed system?
You will need to ask: 1) PMAE if the patient would qualify (give massive arguments: reduced mobility, poor hygiene, old age, risk of caregiver burnout) 2) Pump company for a pump + tubing for a test for about a week 3) Nestlé or Abbott feeding (closed or open system) for a test for about a week
78
Tools checklist
• Gloves • Measuring tape (to measure the length of the tube out of the stomach to check if tube is moving in and out of stomach) • Alcohol swabs (if we want to manipulate) • Feeding tubes, feeding bags • Mini tyrap • Tube adaptor • Syringe (10 mL, 60 mL) • Attachment device • Declogging protocol (always give paper copy + explanations) • RAMQ form • Renewal MENP form May give them a clear schedule of feeding, flush and medication “How to” feeding guide

Clin 2 (3 decks)

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