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CNSC Exam > Initiating Enteral Nutrition Overview > Flashcards

Initiating Enteral Nutrition Overview Flashcards

1
Q

What is the maximum hang time for closed-system enteral formulas

A

48 hours (or based on manufacturer’s guidelines)

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2
Q

A 74 year old male with history of Alzheimer’s dementia and dysphagia requires enteral nutrition as his sole source of nutrition. He presents to the hospital with a fever, hypotension, poor skin turgor an dry mucous membranes. He is 5 feet 9 inches tall and 67 kg. He is currently getting 1200mL of free water daily from the EN + 400 mL from free water flushes. His estimated calorie needs are 1800 kcals/day. How should his fluid needs be estimated?

A

30mL per kg of body weight as using mL /kcal is NOT appropriate and can lead to overhydration

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3
Q

what are three methods for estimating fluid needs in enterally fed patients

A

1mL per kcal of enteral feeding (<65 years old)
Weight based (25-35kcal/kg) for adults > 65 years old
Holliday-Segar Method (1500mL for the first 20 kg and 15mL/kg for each kg remaining over 20kg)

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4
Q

how is the Holliday-Segar Method calculated in adults

A

1500mL of fluid for the first 20 kg

add an additional 15ml/kg over 20 kg

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5
Q

weight based fluid calculations are not recommended for

A

patients with cardiac/kidney failure issues as can lead to fluid overload

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6
Q

A 56 year old female with dysphagia who is afebrile weighs 60kg, is on a standard 1kcal/mL enteral formula at 180mL/hr for 10 hours nightly. What volume of water flushes would best meet her daily estimated fluid requirements

A

1mL/kcal = 1800 mL of total water needed (same as 30mL x 60 kg of water = 1800mL)
Tube Feed Volume + 180mL/hr x 10 hours = 1800 mL, a 1mL/kcal formula contains 84% water, so 1800 x0.840 is approx 1500mL so 1800mL - 1500 mL from tube feed leaves over 300 mL of water for free water flushes

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7
Q

Adult, afebrile patients who are enterally fed can have their fluid needs calculated by

A

1mL or 30-40mL/kg

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8
Q

Standard enteral formulas that are 1mL/kcal contain ____% water

A

84%

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9
Q

what are the benefits of starting early, appropriate enteral feedings

A

decreased bacterial translocation in the gut
preserves gut mucosal lining to decrease infection risk
decreases atrophy of the intestinal villi

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10
Q

lack of feeding via the gut during critical illness may lead to ____ of the intestinal villi, predisposing a patient to _____, increased gut ___ and potentially increased ____ risk

A

atrophy
bacterial translocation of the gut
increased gut permeability
increased infection risk

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11
Q

A patient is receiving EN during her 2nd trimester of pregnancy. Nutrition assessment data reflects an average maternal weight gain of 0.42 pounds a week, normal fetal growth, an albumin of 0.2 g/dL and a nitrogen balance of +2 grams a day. based on the data provided, which parameters are useful in assessing efficacy of enteral nutrition in pregnancy. Which ones are not?

A

Good indicators: maternal weight gain, fetal growth

Poor indicators: albumin, protein

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12
Q

what are the most important factors in assessing adequacy and efficacy of enteral nutrition in pregnancy?

A

fetal growth & maternal weight gain

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13
Q

there is a strong correlation between infant birth weight and ______ weight

A

maternal

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14
Q

a positive nitrogen balance indicates adequate

A

protien provision

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15
Q

A diabetic patient with early satiety, bloating, occasional vomiting & extensive weight loss. After a thorough GI workup, the patient is diagnosed with gastroparesis. What type of EN formula is most efficacious?

A

concentrated (if sensitive to volume)
standard/polymeric (esp. if given jejunum)
low in fat and fiber to avoid delayed gastric emptying

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16
Q

elemental formulas are reserved for patients with

A

malabsorption and pancreatic insufficiency

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17
Q

high protein enteral formulas are reserved for patients with

A

wound healing and critical care nutrition

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18
Q

Lactose is a common ingredient in which type of EN formula?

A

standard infant formula as it mimics the carbohydrate content found in human milk

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19
Q

Most adult medical nutrition products are _____ free because many adults are lactose intolerant, and lactase efficacy is decreased during illness

A

lactose

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20
Q

Patients with chyle leaks will have trouble tolerating polymeric EN formulas becuase

A

they cannot absorb long chain fatty acids well

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21
Q

Elemental EN formulas contain individual _____ and 2-3% of calories from these types of fats ______

A

amino acids

long chain fatty acids

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22
Q

Patients with chyle leaks need to decrease the quantity and duration of chyle loss using ___ formulas and a ______ diet

A

elemental

low fat

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23
Q

patients with Chron’s or Celiac Disease usually do well with intact macronutrients true or false

A

true

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24
Q

patients with gastroparesis can usually tolerate polymeric enteral formulas especially wehn

A

they are provided in the jejunum

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25
Q

In patients with pancreatitis, which parameters are important in predicting tolerance of enteral feedings?

A

APACHE II Score
Duration of NPO
Abdominal pain

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26
Q

What is the most influential factor to determine tolerance of enteral nutrition in pancreatitis

A

disease severity as measured by APACHE II Score

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27
Q

A duration of NPO > _____ days has indicated poor tolerance to EN in studies for pancreatitis

A

6 days

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28
Q

Increased ______ is a clinical indication of enteral feeding intolerance in patients with pancreatitis

A

abdominal pain

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29
Q

what is the rationale for starting EN

A

it may be started in patients who cannot or will not eat adequately

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30
Q

Prior to starting EN, what should be considered

A 
ethics
patient & family wishes
quality of life
risks & benefits
clinical status
prognosis
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31
Q

EN should be started when patients are expected to or have not had adequate oral intake for ______ days

A

7-14 days

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32
Q

EN should not be initiated if the expected duration is less than ____ days in the malnourished patient or less than ____ days in an adequately nourished pateint

A

5-7 days (malnourished)

7-10 days (adequately nourished)

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33
Q

EN should only be started when the patient is

A

fully resuscitated or stable

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34
Q

What is the preferred method of nutrition for open abdomen

A

enteral

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35
Q

when should PN be started in open abdomen when

A

EN isn’t tolerated for greater than 7 days

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36
Q

PN is indicated in high output mid-jejunal fistula, intractable obstipation & vomiting and short bowel syndrome with < _______ cm and without a ______

A

<50 cm w/ out a colon

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37
Q

what are common indications to place a gastro-jejunostomy tube?

A

diabetic gastroparesis as it bypasses the stomach to prevent nausea, vomiting during feeding

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38
Q

Skin level or low profile enteral access devices have what desire features?

A

more comfortable
more cosmetically pleasing
can be capped when not in use

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39
Q

what are cons of low profile enteral access devices

A

they require an access connector to provide meds or feedings & requires manual dexterity

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40
Q

what is the gold standard for determining proper position of a feeding tube placed at the bedside?

A

radiographic confirmation

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41
Q

do auscultation, pH testing, aspiration still require cxr

A

yes

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42
Q

placement of a jejunostomy feeding tube would NOT be beneficial in _____ as it would increase stool output , decreased absorption

A

short bowel syndrome

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43
Q

what are uses for jejunostomy

A

gastroparesis, pancreaticduodenectomy (whipple), chronic pancreatitis

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44
Q

for patients with short bowel syndrome what type of enteral feeding is recommended

A

slow, continuous infusion in the stomach to maximize absorption and intestinal transit time

45
Q

compared to gastric feeding, small bowel feeding is associated with which of the following outcomes in critically ill patients

A

increased nutrient delivery, reduced GRV and reflux, shorter time to get to target goal

46
Q

what intervention may assist with the appropriate placement of a nasogastric feeding tube in an alert patient?

A

elevated the HOB
have the patient in a sitting position
take small sips of water

47
Q

what is most likely to facilitate transpyloric placement of a nasoenteric feeding tube

A

fluoroscopy & endoscopy or bedside electromagnetic imaging system

48
Q

what are contraindications for the placement of a PEG in a patient with liver disease

A

ascites (it may prevent the gastric and abdominal wall from being in close proximity so the trocar won’t be able to pass through the stomach wall with a poor seal possibly leading to peritonitis

49
Q

what are POSSIBLE contraindications to PEG tube placement when risk vs. benefit should be evaluated

A 
esophageal & gastric varices
coagulopathy
hepatic encephalopathy
fulminant hepatic failure
portal HTN
50
Q

What is an advantage of a gastrostomy feeding tube compared to an NG tube

A

gastrostomy tubes can be used in long term needs

51
Q

When EN is needed for over 4 weeks what type of feeding tube is preferred

A

gastrostomy

52
Q

do gastrostomy tubes decrease the risk of aspiration

A

no, but the due have an increased risk of gastric perforation

53
Q

Ascites is considered a relative contraindication to PEG tube as it increases the risk of

A

peritonitis

54
Q

A patient with a traumatic brain injury will require enteral nutrition for three weeks. What is the preferred method of feeding tube placement

A

naso-enteric

55
Q

what are the risks of an open feeding tube, laparoscopic feeding tube and endoscopic feeding tube placement

A

bleeding, anesthesia, bowel perforation , infection

56
Q

What is the primary advantage of a direct percutaneous endoscopic transgastric placed jejunal (PEG-J) tube vs a a PEJ

A

the PEG-J has a decreased risk of migration into the stomach

57
Q

placement of a percutaneous endoscopic _____ tube increases the risk of developing a gastric outlet obstruction

A

PEJ tube

58
Q

What characteristic of EN formulas is MOST likely to increase splanchnic blood flow in a critically ill patient?

A

high fat enteral formulas

59
Q

high fat enteral nutrition helps promote what in a critically ill patient

A

blood flow to the bowel is maxamized

60
Q

what type of enteral nutrition formula is ideal for patients at high risk for intestinal ischemia, as adequate bowel perfusion is needed for tolerance of high fiber, high osmolarity

A

isotonic, fiber free

61
Q

Hospital prepared enteral nutrition formulas should be stored at approximately what temperature

A

4 degrees C to 39 degrees F

62
Q

what is considered the danger zone for food contamination

A

5-57 decrees C

63
Q

A 60 year old female is admitted with a stroke and fails a swallowing evaluation. An NG tube is placed and the MD requests an isotonic formula. What calorie density of EN formulas is isotonic

A

1 kcal/mL which is about 300 mOsm/kg

64
Q

what is the range of osmolarity for 1kcal/mL EN formulas

A

300-350 mOsm/kg

65
Q

what is the range of osmolarity for 1.2 kcal/mL EN formulas

A

400-450 mOsm/kg

66
Q

what is the range of osmolarity for 1.5 kcal/mL EN formulas

A

500-650 mOsm/kg

67
Q

what is the range of osmolarity for 2 kcal/mL EN formulas

A

700-800 mOsm/kg

68
Q

what is the best initial enteral feeding regimen for a critically ill adult

A

full strength started at a low rate and slowly advance to goal

69
Q

why is it not encouraged to dilute enteral formulas

A

it can cause microbial growth and inadequate nutrition provision

70
Q

What is the most important intervention to decrease the risk of pulmonary aspiration during gastric tube feedings

A

elevated the HOB 30-45 degrees

71
Q

drugs that cause diarrhea are due to their

A

hypertonicity, laxative action from sorbitol or magnesium containing products

72
Q

what are drugs/medications that are known to cause diarrhea

A

medications containing sorbitol, magnesium citrate, antibiotics that cause enteritis, high TF osmolarity/bolus (sometimes)

73
Q

tube feeding is often held 2 hours before and after enteral administration of these types of meds

A 
warfarin
ciprofloxacin
phenytoin
carbamazepine
fluoroquinolones
74
Q

what strategies can be employed to reduce the risk of feeding tube occlusion

A

flush with water before and after each medication

75
Q

drugs that are microencapsulated with beads or pellets are most effectively administrated through large bore feeding tubes when mixed with _______ due to the acidity to reduce the beads/pellets from sticking to the tube. The tube should also be flushed with water before and after the OJ and separately from the EN formula. Don’t use warm water.

A

orange juice

76
Q

what type of enteral formulas are least likely to be contaminated with microorganisms

A

ready to hang

77
Q

what is the hang time of formula made from reconstituted powder

A

4 hours

78
Q

what is the hang time of home made blenderized enteral formulas

A

2 hours

79
Q

what is the hang time of commercially made blenderiezed enteral formulas

A

4-8 hours

80
Q

A 45 year old male is admitted with stage 4 pressure wounds, sepsis and acute respiratory failure who requires mechanical ventilation. BUN is stable, no additional excessive GI losses are noted. A polymeric high protein EN formula was started on day 1 of admit. On day 7, the primary care team requested an eval of the protein dose provided by EN. The EN formula gives 136 grams of protein (1.5g/kg/day). What is the best method to assess protein adequacy

A

nitrogen balance study

81
Q

_____ is the gold standard for assessing the adequacy of protein intake in the acute hospital setting

A

nitrogen balance

82
Q

Nitrogen balance is the difference of

A

nitrogen intake -nitrogen output

83
Q

nitrogen output as part of a nitrogen balance study is measured from

A

urine urea nitrogen from a 24 hour urine collection

84
Q

nitrogen intake as part of a nitrogen balance study is measured from

A

EN or PN intake

85
Q

what are limitations to using a nitrogen balance study

A

renal dysfunction, errors estimating output and intake

86
Q

Use of a semi-elemental or elemental formula in place of a polymeric formula should be considered with

A

intolerance to polymeric formula

87
Q

Use of immune modulating formula may be beneficial in

A

elective surgery, TBI, abdominal and torso injury from a MVA crash

88
Q

immune modulating formulas contain

A

arginine, glutamine, nucleotides, omega 3 fatty acids

89
Q

the use of immune modulating formulas is not recommended for routine use

A

use is controversial, there are inconsistent outcomes and contraindicated in septic patients 2/2 adverse effects with arginine

90
Q

what would be the most appropriate TF formula for a patient with extensive second degree burns

A

high protein

91
Q

high protein EN formulas are needed in severe burns because

A

burns cause a breakdown of lean muscle for energy and loss from wounds

92
Q

What are types of modular products for EN

A

MCT Oil
Glucose
Fiber
Protein

93
Q

what are EN modulars used for

A

to fortify EN regimens or meals

94
Q

EN modulars should not be added directly to

A

enteral formula

95
Q

Early initiation of EN has been a suggested benefit LICU patients by reduction infectious complications, length of stay and possibly decreased mortality. Which group of patient’s might be at significant risk from early EN.

A

patients with increased vasopressor support which may increase the risk of intestinal ischemia from decreased blood perfusion

96
Q

a patient with ARDS getting EN will benefit most from

A

avoidance of overfeeding

97
Q

this disease is associated with inflammation causing alveolar damage and lung capillary endothelial injury

A

ARDS

98
Q

Formulas with omega 3’s are thought to be used for ARDS because

A

the omega 3 fatty acids, arginine, and glutamine may down regulate the inflammatory response induced by ARDS

99
Q

immune modulating formulas with omega 3 fatty acids are not recommended for routine use in ARDS because

A

research remains inconclusive

100
Q

The use of EN formulas enriched with branched-chain amino acids may benefit with

A

refractory encephalopathy

101
Q

Theory: liver failure is thought to increase the ratio of aromatic amino acids (AAA) to branched chain amino acids (BCAAs). BCAAs also decrease from muscle breakdown. Increased AAAs develop “fake neurotransmitters” causing encephalopathy. Only use formulas with increased BCAAs if a patient is still encephalopathic despite medicine

A

encephalopathy

unresponsive to standard medical therapy

102
Q

EN may be contraindicated in early post transplant period with hematopoietic cell transplants because of

A

potential mucosal toxicities r/t conditioning regimen that causes to GI toxicities that cause, nausea, vomiting, delayed gastric emptying, diarrhea within the first 2-3 weeks of post stem cell transplant may provide EN

103
Q

in patients with early post transplant period with hematopoietic cell transplants what form of artificial nutrition is recommended

A

there is insufficient data to establish the benefits of enteral nutrition over parenteral nutrition for hematopoietic cell transplants

104
Q

which medication would be appropriate to crush and deliver via enteral nutrition tube

A

immediate release

105
Q

____ medications should not be crushed to be put through a feeding tube as can cause medication toxicity

A 
slow release 
typical abbreviations (XL, XR,SR,CD)
106
Q

which describes an optimal method of preparing and administering meds via enteral tube

A

flush the tube with water before and after each medication

107
Q

in patients with severe acute pancreatitis, EN has been documented to provide the following benefits over parenteral nutrition

A

EN will decrease infection rate, decrease length of stay and decrease mortality

108
Q

In a pt with fat malabsorption of an enteral products containing which of the following concentrated source of energy

A

MCT’s; they are absorbed directly into the blood stream into the portal circulation by passing need for pancreatic enzymes, bile carnitine dependent transport into the mitochondria

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