Module 7 - Home Nutrition Support (V.5)

Question 1

Initially, how often should electrolytes be monitored in a patient on home parenteral nutrition support?
A. Daily
B. Weekly
C. Monthly
D. Bi-monthly

Answer 1

B. Weekly

A.S.P.E.N. recommends weekly monitoring of serum glucose, electrolytes, blood urea nitrogen, creatinine, magnesium and phosphorus for four weeks or until the patient is clinically stable. Some patients may warrant more frequent lab monitoring.

Question 2

Which of the following is a key concept that should be included in the post-discharge teaching regimen for a home parenteral nutrition (HPN) patient?
A. Reimbursement requirements
B. Normal laboratory values
C. Signs and symptoms of possible complications
D. Components of the parenteral nutrition (PN) formula

Answer 2

C. Signs and symptoms of possible complications

Complications that can be easily identified by patients or caregivers should be reviewed during post-discharge teaching. These complications can be identified and relayed to the appropriate healthcare professional. Reimbursement requirements should be taken care of before the patient is home. Laboratory values and components of the PN formula should be addressed by heathcare professionals.

Question 3

Which of the following vascular access devices (VADs) should not be used for home parenteral nutrition (HPN)?
A. Hickman catheter
B. Peripherally-inserted central catheter (PICC)
C. Midline catheter
D. Implanted port

Answer 3

C. Midline catheter

Placement of a permanent VAD is essential prior to discharging a patient on HPN therapy. Patients should not be sent home with a temporary catheter for HPN use. VADs must be placed in the central venous system to accommodate hyperosmolar HPN solutions. Types of VADs approved for HPN administration include: (1) tunneled central venous catheters; (2) implanted ports; and, (3) peripherally inserted central catheters. Midline catheters are short-term VADs typically used for therapies lasting 2-4 weeks.

Question 4

Which of the following is the MOST practical approach for managing micronutrients in long-term parenteral nutrition (PN) patients?
A. Obtain serum values for all vitamins and trace elements yearly
B. Perform a micronutrient assessment every 6 months
C. Provide micronutrients only when laboratory values indicate abnormal levels
D. A nutrition focused physical assessment should be performed annually to determine micronutrient deficiencies

Answer 4

B. Perform a micronutrient assessment every 6 months

Currently, the most practical approach to managing micronutrients and monitoring micronutrient status in long-term PN patients is to perform a micronutrient assessment every 6 months. During this assessment, the clinician reviews nutrient intake, potential nutrient losses, medications, and medical/surgical history, and performs a nutrition-focused physical examination. Every patient should receive micronutrients daily unless there is a potential or identified nutrient toxicity, or adjust accordingly if there is a national shortage of product. Whenever a nutrient is omitted or added to standard micronutrient recommendations, the patient should be monitored for a potential deficiency or toxicity that could develop over time. 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.

Question 5

Which of the following is accurate about the use of ethanol as a lock solution?
A. Ethanol has an effect on microbial resistance
B. Ethanol has no effect on polyurethane VADs
C. Ethanol has an effect on biofilm formation
D. Ethanol has no effect on heparin

Answer 5

C. Ethanol has an effect on biofilm formation

There is no known microbial resistance to ethanol. A 70% ethanol lock (ELT) solution removes the luminal biofilm inside VADs in which microorganisms are harbored. They can detach from the biofilm and seed the bloodstream causing CLABSI. ELT should be considered to rpevent recurrent infections. Studies are ongoing whether ELT should be used as standard care, treatment or prevention of infections. ELT increases breakage and thrombosis and weakens VADs made from polyurethane. Ethanol is incompatible with heparin.

Question 6

Failure to monitor which micronutrient in long-term parenteral nutrition (PN) patients is most likely to result in toxicity?
A. Manganese
B. Zinc
C. Folate
D. Molybdenum

Answer 6

A. Manganese

Hypermanganesemia can occur in all patients on long-term PN, regardless of liver function. A 2009 ASPEN review of commercially available PN formulas indicated they contain potentially toxic levels of Manganese, Copper, and Chromium. ASPEN is working with the FDA for product reformulations. In 2012 ASPEN decreased Manganese and Copper dose recommendations were made. Manganese toxicity symptoms include headache and Parkinson-like abnormalities. While zinc and folic acid are important nutrients, not all patients are at risk for those specific deficiencies, and toxicity symptoms are not reported in those using standard PN. There is little found in the literature about molybdenum deficiency or toxicity in long-term PN patients, and routine monitoring is not recommended.

Question 7

Medicare approved indications for home parenteral nutrition (HPN) include which of the following?
A. Supplement to enteral nutrition
B. End-stage renal disease (ESRD)
C. Long-term loss of gastrointestinal function
D. Delayed gastric emptying

Answer 7

C. Long-term loss of gastrointestinal function

Medicare requires home parenteral nutrition be required for long-term therapy, usually greater than 90 days with evidence of loss of gastrointestinal function and when enteral feedings have failed. Supplemental HPN is rarely covered at home by Medicare since the use of EN indicates that the gut is functional. ESRD is not an indication for PN in and of itself as ESRD is not a diagnosis involving the small bowel or the bowel’s ability to absorb nutrients. Any inability to tolerate a gastroparesis diet will result in small bowel EN feeding to bypass the stomach. Medicare will approve HPN if there is evidence of fat malabsorption.

Question 8

Following initial certification of parenteral nutrition by Medicare, after what length of time is recertification required?
A. 6 months
B. 1 year
C. 1 month
D. Never

Answer 8

A. 6 months

After initial certification for parenteral nutrition is obtained, recertification is required after 6 months of therapy. The recertification process is used to document the patient’s continued need for therapy; additional recertifications may be requested on an individual basis.

Question 9

The clinical manifestations of copper deficiency can be similar to what other micronutrient deficiency?
A. Vitamin B12
B. Manganese
C. Vitamin E
D. Zinc

Answer 9

A. Vitamin B12

Assessing micronutrient status in long-term home parenteral nutrition (HPN) consumers is challenging, requiring astute symptom observation. This may be complicated when one deficiency mimics another. The most common manifestations of hypocupremia include anemia, leukopenia (primarily neutropenia), foot numbness, and gait difficulty. Hematological and neurological abnormalities often coexist but may occur independently. Anemia associated with copper deficiency may be normocytic, macrocytic, or microcytic. Hypocupremia is associated with dysfunction of the spinal cord, resulting in paresthesia and numbness in the lower extremities, sensory ataxia, and occasionally a spastic gait. These neurological presentations are also associated with vitamin B12 deficiency.

Question 10

Medicare reimbursement for home and community-based professional nutrition education services provided by a registered dietitian is restricted to patients who
A. live alone.
B. have cancer.
C. are over the age of 65.
D. have diabetes or renal disease.

Answer 10

D. have diabetes or renal disease.

Medicare reimbursement for home and community-based professional nutrition education services provided by a registered dietitian covers patients with diabetes, pre-dialysis kidney disease, and those who previously had a kidney transplant.

Question 11

Which of the following is the best way to determine chromium deficiency?
A. Serum chromium levels
B. Urinary chromium levels
C. There is no known reliable indicator of chromium status
D. Serum glucose to insulin ratio

Answer 11

C. There is no known reliable indicator of chromium status

Chromium potentiates the action of insulin and has a role in glucose, protein, and lipid metabolism. Pregnancy and type 2 diabetes can potentially lead to increased urinary excretion of chromium. 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. There are no known reliable indicators of chromium status and levels in the blood are present in extremely low concentration making detection difficult.

Question 12

A 69 year old 70 kg male is on continuous high protein high fiber feeding running at 65mL/hr via PEG. The TF was selected to assist with wound healing and diarrhea. The TF is stopped every 6 hrs, residuals checked and tube is flushed with 30mL water. The patient is provided liquid medications through the feeding tube 2x day. The tube becomes occluded. The most likely reason the tube becomes occluded is:
A. Frequent GRV checks
B. Inadequate flushing of feeding tube
C. High protein, high fiber formula
D. Liquid medication administration vs. crushed tablets mixed in water.

Answer 12

B. Inadequate flushing of feeding tube

The best practices to maintain tube patency and prevent tube clogging include: 1) Use the largest diameter feeding tube feasible. Large bore tubes are less likely to clog by either medications or viscous formulae. 2) Flush feeding tubes immediately before and after intermittent feeds or at standardized intervals with continuous feeds. 3) Flush feeding tubes before/after medication administration. 4) Limit gastric residual checks as acidic gastric contents may cause protein in enteral formula to precipitate within the lumen of the tube. Prevention is the preferred way to minimize the risk of enteral feeding tube occlusions. Consistent and scheduled flushing of all tubes is best practice. No solution has been found to be superior to water for its effectiveness, accessibility and cost. Water used for tube flushing can be drinking water or sterile water. Medications in liquid form are less likely to occlude tube than crushed pills and should be used if available. Each medication should be given separately with a water flush before/after each administration.

Question 13

Which of the following are considered the lowest risk candidates for initiation of parenteral nutrition (PN) in the home setting?
A. infants.
B. teenagers.
C. dialysis patients.
D. diabetic patients.

Answer 13

B. teenagers.

Infants, intravenous drug abusers, patients with diabetes, fluid and electrolyte/acid-base disorders, and those at risk for refeeding syndrome may not be ideal candidates for initiation of PN in the home setting. Patients with these conditions may need more frequent monitoring and clinical assessment than can be managed at home. Teenagers are typically not thought to be at high risk for problems when PN is initiated in the home setting.

Question 14

Home infusion companies are responsible for providing the following services for parenteral and enteral therapies EXCEPT
A. formula delivery.
B. equipment and supplies delivery.
C. infusion nursing care.
D. patient support groups.

Answer 14

D. patient support groups.

Home infusion providers are responsible for the delivery of nutritional products, appropriate supplies for the delivery of nutrition, and the nursing care required to educate about and monitor the prescribed therapy. Patient support groups, while often appropriate for a homebound patient, is not typically a responsibility of the home infusion company.

Question 15

During discharge education, which of the following is the BEST way for a home nutrition support provider to know if a patient and/or caregiver understands enteral tube feeding delivery?
A. Verbal description of proper techniques
B. Written explanation of proper techniques
C. Appropriate responses to questions asked
D. Return demonstration of procedure techniques

Answer 15

D. Return demonstration of procedure techniques

Based on research, one of the most effective ways to improve understanding of discharge teaching while simultaneously addressing health literacy is the “teach-back” process. The “teach-back” process is an active process in which the learner can demonstrate health care skills and verbalize home care instructions. This process allows the educator to verify understanding, to correct inaccurate information, and to reinforce new home care skills.

Question 16

According to Medicare (and Medicaid) guidelines, under the prosthetic device act, home enteral nutrition (HEN) is covered for a patient who
A. cannot meet his/her nutrition requirements by oral intake.
B. has documented weight loss of 10% in 3 months and refuses to eat.
C. has a permanent disease of the structures that normally permit food to reach the small bowel.
D. has a temporary (estimated as less than 3 months) impairment or disease of the mouth, esophagus or stomach that prevents food from reaching the small bowel.

Answer 16

C. has a permanent disease of the structures that normally permit food to reach the small bowel.

Under Medicare coverage guidelines for HEN, the beneficiary must meet one of two criteria: 1) a permanent non-function or disease of the structures that normally permit food to reach the small bowel; or 2) a disease of the small bowel that impairs digestion and absorption of an oral diet. The beneficiary must also meet the test of permanence, which is based on the judgment of the attending physician and is substantiated in the medical record. “Permanence” means that the condition is of indefinite duration, 90 days or greater. Permanence does not exclude the possibility of improvement. Additionally, the beneficiary must require tube feeding to maintain weight and strength commensurate with overall health status, and adequate nutrition must not be possible by dietary adjustment and/or oral supplements.

Question 17

Managed care and private insurance companies often use which established criteria/guidelines when approving coverage for home parenteral nutrition (HPN)?
A. Medicare criteria
B. State-funded Medicaid program criteria
C. Oley Foundation criteria
D. ASPEN Standards for Specialized Nutrition Support: Home Care Patients

Answer 17

A. Medicare criteria

Insurance coverage for home enteral nutrition (HEN) and HPN varies by type of program as well as individual plans. Government programs(eg. Medicare and Medicaid) have strict coverage criteria and require detailed history, tests and nutritional data to determine eligibility. Coverage policies and reimbursement for HEN and HPN also vary with private payers and managed care organizations and frequently require preauthorization or precertification. Most require that the therapy be medically necessary and the sole source of nutrition. Many insurance policies establish their own criteria for EN and PN, while others follow the guidelines for coverage set forth by Medicare.

Question 18

To meet the Medicare payor criteria for home enteral or parenteral nutrition, the patient’s condition must be considered to be “of long and indefinite duration”. Which length of time below meets Medicare’s test of permanence requirement?
A. 30 days.
B. 60 days.
C. 90 days.
D. 120 days.

Answer 18

C. 90 days.

EN and PN are primarily covered under the “prosthetic device” benefit under the Medicare Part B program. This provision requires a permanent dysfunction of a body organ. For EN or PN to be reimbursed by Medicare, the therapy requirements must fit into a defined benefit category and be “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body part.” For either therapy, there must be “provision of sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status,” and the condition must have a “permanent impairment of long and indefinite duration” of at least 3 months.

Question 19

Upon initiation of home parenteral nutrition (HPN), initial laboratory data should be obtained
A. within 48 hours after initiation.
B. prior to initiation.
C. the day of initiation.
D. within 1 week of initiation.

Answer 19

B. prior to initiation.

Laboratory data should be obtained prior to HPN initiation. More frequent assessment of laboratory data may be required to ensure efficacy and prevent complications of nutrition support when initiated in the home.

Question 20

Which non-profit organization is a great resource for home parenteral/enteral patients and their caregivers?
A. Academy of Nutrition and Dietetics
B. American Society of Clinical Nutrition
C. Association of Gastrointestinal Motility Disorders
D. American Society of Parenteral and Enteral Nutrition

Answer 20

C. Association of Gastrointestinal Motility Disorders

Association of Gastrointestinal Motility Disorders was incorporated in 1991 and is one of the oldest nonprofit organizations in existence, with a focus on digestive motility diseases and disorders. The association understands needs of patient groups as well as their caregivers, resulting in the creation of the pediatric, young adult, adult, senior citizen, caregiver, and family divisions. Additionally, the Oley Foundation is 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.

Question 21

The most common complication seen after percutaneous endoscopic gastrostomy (PEG) tube placement is:
A. Buried bumper syndrome
B. Peristomal infection
C. Gastric ulceration
D. Colocutaneous fistulas

Answer 21

B. Peristomal infection

Post-procedural complications present days to months after placement. Infection around the insertion site is a relatively common post-procedural complication reported in up to 30% of tubes placed. Buried bumper syndrome is a result of erosion of the internal bolster into the gastric mucosa and occurs in 0.3-2.4% of patients. Ulceration of the gastric mucosa is 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. Colocutaneous fistulas occur when the colon is inadvertently punctured during placement. It is extremely rare, occurring in only 0-0.27% of cases.

Question 22

Which of the following diagnoses would meet Medicare Part B coverage criteria to qualify a beneficiary for home enteral nutrition?
A. Dysphagia
B. Aspiration pneumonia
C. Anorexia
D. Malnutrition

Answer 22

A. Dysphagia

Home enteral nutrition is a covered Medicare Part B benefit for a patient who has a permanent condition or disorder (>90 days) that impairs food from reaching the small bowel or disease of the small bowel that impairs digestion and absorption of adequate nutrition. The beneficiary must require tube feeding to provide adequate nutrients to maintain weight and strength to align with their overall health status. The patient’s condition could be either anatomic, e.g. obstruction due to head and neck cancer or reconstructive surgery, or due to a motility disorder, e.g. severe dysphagia following a stroke. Enteral nutrition is not covered for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia, malnutrition, or nausea.

Question 23

Which trace element deficiency is most likely to occur in long-term parenteral nutrition (PN)-dependent patients after 3 to 6 months of therapy?
A. Iron
B. Copper
C. Chromium
D. Manganese

Answer 23

A. Iron

Iron is not a component of the parenteral nutrition (PN) formulation in part to avoid potential contribution to microbial growth and damaging oxidative reactions. Parenteral iron should be considered in conditions of iron deficiency when the oral route is ineffective or not tolerated. Patients with iron deficiency anemia may present with fatigue, headache, pallor, reduced work performance, impaired behavioral and intellectual performance, and impaired ability to maintain body temperature. Iron is not compatible with a 3-in-1 PN solution but may be added to a 2-in-1 PN solution. Iron dextran, the preferable form to add to PN, may be added only after the patient has been given a test dose to evaluate tolerance and avoid anaphylactic reactions. Serum iron and ferritin levels should be monitored routinely every 1 to 3 months if a repletion dose is added to the PN solution to prevent iron overload.

Question 24

Which of the following is true concerning aluminum contamination in long-term parenteral nutrition (PN)?
A. The amount on the manufacturer’s label is greater than measured amounts
B. Each PN bag must provide the amount of aluminum per liter
C. The clinical manifestations of aluminum toxicity are specific and sensitive
D. Aluminum toxicity is the primary etiology of parenteral nutrition-associated bone disease

Answer 24

A. The amount on the manufacturer’s label is greater than measured amounts

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. The amount on the label has been shown to be approximately 10 times more than what was actually measured in a PN bag prepared according to a patient’s prescription. Pharmacies are not required to list the aluminum content on each patient’s PN bag. The clinical manifestations of aluminum toxicity (neurological, hepatic, hematologic, and skeletal) are neither specific nor sensitive for aluminum toxicity. The etiology of parenteral nutrition-associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors.

Question 25

Which of the following enteral feeding schedules should be recommended to patients and their families when preparing for home enteral nutrition?
A. Continue the same schedule as the patient had in hospital
B. Schedule feedings during meal times
C. Integrate feeding into the patient’s and family’s lifestyle
D. Separate the patient during meal time to minimize the family’s discomfort with the process

Answer 25

C. Integrate feeding into the patient’s and family’s lifestyle

In the home, enteral feeding should be integrated into the patient’s and family’s typical way of living. Separation of the patient from the family during meal times may have a negative impact on the family structure, although the administration of tube feeding may not be accepted by some at the dinner table. A compromise may be necessary to meet all the family members’ needs. Participation in conversations and socialization at the dinner table is encouraged. When possible in the home setting, the administration schedule should be structured to simulate normal meal times. There is evidence that patients and their caregivers quickly adapt the prescribed enteral feeding regimen to suit themselves and their home circumstances.

Question 26

Which of the following data should be collected in the home care provider’s performance improvement plan?
A. First-dose precautions
B. Discharge instructions
C. Hospital readmission
D. Consent for care

Answer 26

C. Hospital readmission

Nutrition support is a high-risk, problem-prone treatment and should be addressed in the home care provider’s performance improvement and outcome measurement activities. Data to be collected should include but not be limited to mortality, hospital readmission, complications, patient/family satisfaction, and problem reporting and resolution. Although first-dose precautions, discharge instructions, and consent for care are an important part of planning for a home nutrition support patient they are not traditionally an integral component of a performance improvement plan.

Question 27

Which of the following is true regarding the concept of quality of life in home parenteral nutrition (HPN) patients?
A. Most patients believe that the HPN access catheter has little effect on their self-image or self-esteem
B. Patients with chronic bowel disease seem to cope less effectively than patients with acute gastrointestinal trauma
C. Social isolation is not an issue since most infusions are cycled over night
D. Adjusting to HPN is easier for patients who structure HPN around their specific lifestyles

Answer 27

D. Adjusting to HPN is easier for patients who structure HPN around their specific lifestyles

Patients who have been able to maintain stability in their personal lives towards employment, family support and financial security, seem to adjust better to HPN and have a more positive outlook on the future. A source of concern for most HPN patients is the cosmetic effect of the catheter. Patients with chronic bowel disease seem to cope more effectively since they often see relief from frequent hospitalizations and abdominal discomfort. While HPN is often cycled at night, the inability to eat can significantly affect social quality of life.

Question 28

When evaluating the home environment for a patient receiving parenteral nutrition, which of the following is required?
A. Access to telephone
B. Isolated infusion area
C. Back-up electrical generator
D. Dedicated refrigerator

Answer 28

A. Access to telephone

Patients receiving home parenteral nutrition require a home/cellular telephone or other means of contacting someone outside of the home in the event of a medical emergency. The appropriate health care personnel or emergency center must be contacted as soon as possible. If there is frequent interruption of electrical service, a back-up battery-powered infusion pump may be needed. A back-up electrical generator is not required. While preferred, an isolated infusion area and dedicated refrigerator are not required. However, an area that can be used for supply storage is required.

Question 29

When transitioning a patient from hospital to home parenteral nutrition (HPN) support, screening criteria should include which of the following?
A. Transportation needed to make it to lab draws
B. Presence of electricity and sanitary water supply in the home
C. Access to fingerstick glucose monitoring
D. A caregiver

Answer 29

B. Presence of electricity and sanitary water supply in the home

Sanitary water supply and electricity are needed to safely administer parenteral nutrition. Parenteral nutrition solution requires refrigeration; there will be storage space needed for other associated supplies. Lab draws may be obtained by homecare nurses. 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.

Question 30

Home infusion providers should have policies that address
A. reimbursement criteria for phone consultations.
B. availability of social workers to address psychosocial issues.
C. patient-driven weaning of parenteral nutrition.
D. education, training, and evaluation of patient/caregiver competency.

Answer 30

D. education, training, and evaluation of patient/caregiver competency.

The education, training, and evaluation of patient/caregiver competency is very important for a quality teaching program to facilitate patient and provider independence. There is currently no reimbursement structure for compensation of phone consultations in the US. While it would be helpful in many cases to have social workers and other support agencies available, this is not necessary for a home care policy. They can make referrals as appropriate.

Question 31

According to current Medicare guidelines, coverage for an enteral feeding pump can be justified under which of these circumstances?
A. The patient is being fed using a jejunal feeding tube
B. The patient states a preference to infuse feedings during the night using a pump
C. The patient’s caregiver has difficulty preparing several bolus feedings each day
D. The patient would like enteral feedings to infuse quickly.

Answer 31

A. The patient is being fed using a jejunal feeding tube

Under Medicare guidelines, enteral infusion pumps are covered only with documentation that gravity feeding is not tolerated or contraindicated for situations such as reflux, aspiration, dumping syndrome, glycemic control, circulatory overload, slow infusion rate, or jejunal feeding.

Question 32

Patient education materials for home enteral and parenteral nutrition patients should be written at what grade level?
A. 6th
B. 9th
C. 10th
D. 12th

Answer 32

A. 6th

The estimated mean U.S. reading level is 8th grade. A 5th or 6th grade level is recommended for patient education materials.

Question 33

Skin care around a feeding tube site should be accomplished by cleaning with
A. alcohol.
B. mild soap and water.
C. antibiotic ointment.
D. hydrogen peroxide.

Answer 33

B. mild soap and water.

Skin care around a feeding tube site should be accomplished by cleaning with mild soap and water, rinsing and drying thoroughly. Patients should be taught to clean carefully under external bolsters to remove debris and check for excessive pressure. Routine use of antibiotic ointments is not advised, and dressings at the tube insertion site are not necessary unless there is drainage.

Question 34

A patient on long-term home enteral nutrition suddenly develops nausea and vomiting. The most likely cause is
A. frequent use of sorbitol-containing medications.
B. gastric outlet obstruction.
C. low osmolarity formula.
D. sudden decrease in enteral feeding rate.

Answer 34

B. gastric outlet obstruction.

Causes of nausea and vomiting in the enterally fed patient may include: too rapid of a rate of bolus infusion, gastric outlet obstruction which may be caused by feeding tube migration, excessive feeding volume, and gastroparesis. Gastric irritation or atony/stasis, distal obstruction, anxiety, other diseases, and medication may also cause these symptoms. Nausea and/or vomiting may be prevented or resolved by decreasing the rate or volume of enteral infusion. Frequent use of sorbitol-containing medications is a common cause of tube feeding-associated diarrhea, not nausea and vomiting.

Question 35

Home-prepared or blenderized enteral nutrition (EN) formulations should be discarded after
A. 6 hours.
B. 12 hours.
C. 24 hours.
D. 48 hours.

Answer 35

C. 24 hours.

The use of home-prepared or blenderized EN formulations requires additional attention to nutrient content and safe food handling and storage practices. These formulas should be discarded after 24 hours. Hang time for blenderized or reconstituted formula is 4 hrs.

Question 36

Which of the following conditions is NOT a symptom for zinc deficiency?
A. Loss of taste sensation
B. Anemia
C. Night blindness
D. Gonadal hypofunction

Answer 36

B. Anemia

Zinc deficiency can be a result of inadequate intake, reduced absorption, increased losses, or increased demand. Symptoms can be reported as loss of taste sensation, altered smell sensation, and skin rash in severe cases. Decreased vitamin A release from the liver can contribute to nighttime blindness. Zinc is needed for growth and tissue maintenance, and deficiency can present as growth failure, alopecia, and decreased muscle work capacity. Deficiency can also cause gonadal hypofunction leading to decreased plasma testosterone and fertility. Anemia is not associated with zinc deficiency, but could be a symptom of zinc toxicity if that leads to copper deficiency.

Question 37

Which of the following is true of aluminum toxicity in patients receiving long-term parenteral nutrition?
A. The clinical manifestations of aluminum toxicity are specific and sensitive
B. Aluminum toxicity is the primary etiology of parenteral nutrition-associated bone disease
C. Increased risk of aluminum toxicity exists in the setting of renal failure or iron deficiency anemia
D. Modern manufacturing practices have eliminated the risk of aluminum toxicity

Answer 37

C. Increased risk of aluminum toxicity exists in the setting of renal failure or iron deficiency anemia

Home PN patients with significant renal dysfunction and Fe Deficiency are at risk for aluminum toxicity due to impaired excretion or excessive exposure that aluminum accumulation occurs. The kidneys are responsible for unbound aluminum excretion. The majority of aluminum in the blood stream is bound to protein, primarily transferrin, and cannot be excreted. The clinical manifestations of aluminum toxicity (neurological, hepatic, hematologic, and skeletal) are neither specific nor sensitive for aluminum toxicity. The etiology of parenteral nutrition-associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors. Since many components of PN have an affinity for aluminum, there is still a risk for aluminum toxicity in patients on long term PN support.

Question 38

Of the many online resources for HEN and HPN, which organization provides an annual summer conference and online education modules?
A. Coping Well (www.copingwell.com)
B. Feeding Tube Awareness Foundation (www.feedingtubeawareness.com)
C. Oley Foundation (www.inspire.com/groups/oley-foundation, www.oley.org)
D. Living Life on TPN (https://www.facebook.com/groups)

Answer 38

C. Oley Foundation (www.inspire.com/groups/oley-foundation, www.oley.org)

Many organizations provide important outreach services, free education materials and emotional support to patients, families, and caregivers. The Nonprofit Oley Foundation is a national education, self-help and research organization. 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.

Question 39

Patients/caregivers should receive discharge instructions regarding home enteral nutrition by qualified members of the healthcare team. All of the following is essential information to be taught during education EXCEPT?
A. Volume of formula per feed and total daily volume
B. Administration method and schedule
C. Care of the enteral access device and infection control
D. Total calories and protein provided per day

Answer 39

D. Total calories and protein provided per day

A patient/caregiver should receive discharge instructions that include the name of the formula, total daily volume and route of administration, timing/duration of administration, care of the enteral access device, product hang-time and stability at room temperature, inspection of enteral products for defects and expiration dates, infection prevention and control (i.e., standard precautions), action to be taken in the event of late or missed administration of enteral nutrition and proper storage of opened and unused enteral products. Upon discharge, the patient should be given the contact information for the home care company. It is not necessary for the patient to know the protein and calorie provision. It can be provided if the patient wishes to have this information.

Question 40

Which of the following best defines Good Quality of Life (QOL) for patients receiving HPN?
A. Disease-free
B. Being kept alive
C. Enjoys life, being happy and satisfied with life
D. Better understanding of the prognosis of their condition

Answer 40

C. Enjoys life, being happy and satisfied with life

There is no gold standard measure for QOL, and until recently, no therapy-specific QOL instrument for home nutrition support has been validated. QOL is a multidimensional concept that includes physical health status, psychological well-being, social and cognitive function and illness and treatment.

Question 41

Which of the following is true concerning manganese and patients on long-term parenteral nutrition (PN)?
A. Manganese deficiency occurs in patients on PN for greater than 1 year
B. Hypermanganesemia has been reported only in patients with cholestasis
C. Manganese in commercial trace element preparations may result in hypermanganesemia
D. The best indicator of manganese status is serum manganese

Answer 41

C. Manganese in commercial trace element preparations may result in hypermanganesemia

Hypermanganesemia has been reported in >50% of home PN patients accompanied by clinically significant cerebral and hepatic complications. Manganese (Mn) is almost exclusively excreted via the hepatobiliary system. Therefore, reductions in Mn dosing should be considered in patients with hepatobiliary disease such as cholestatic liver disease. Patients at risk for developing Mn toxicity include those receiving long-term PN (>30 days) who develop obstruction of the biliary duct and are unable to excrete Mn. Supplemental Mn may need to be removed from the PN solution in long-term PN patients. Brain deposition of Mn can occur with IV Mn administration of 1.1 mg/day. Magnetic resonance imaging (MRI) can detect Mn toxicity but the procedure is expensive. The best method of monitoring Mn status is with whole blood Mn levels as they correlate well with MRI abnormalities.

Question 42

A malnourished patient with metastatic ovarian cancer is diagnosed with an inoperable partial mechanical small bowel obstruction. She is taking 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, this patient’s home parenteral nutrition (HPN) will be covered under which of the following circumstances?
A. The physician must write an order for the patient to be nil per os or “nothing by mouth”
B. Medical record must include a radiology report documenting the presence of partial small bowel obstruction
C. Medical record must document failure of an enteral tube feeding trial, or explain why an enteral feeding tube is not an option
D. No further documentation is necessary to confirm coverage

Answer 42

C. Medical record must document failure of an enteral tube feeding trial, or explain why an enteral feeding tube is not an option

Medicare has stringent guidelines for the use of HPN. The diagnosis of nonfunctional gastrointestinal tract is critical to ensure coverage. The diagnosis of partial small bowel obstruction alone will not qualify a person for HPN under present Medicare guidelines. An enteral tube feeding trial must be attempted and shown to fail or explain why a feeding tube is not an option. Medicare criteria for HPN include massive small bowel resection (less than or equal to 5 feet of small bowel distal to the Ligament of Treitz), short bowel syndrome (enteral losses exceed 50% of enteral intake), weight loss 10% in less than or equal to 3 months (serum album below 3.4g/dL, fecal fat tests demonstrating malabsorption or serum albumin below 3.4g/dL, gastrointestinal motility disorder refractory to maximum prokinetic medication, diagnostic test showing dysmotility, complete mechanical bowel obstruction (inoperable), or bowel rest for at least 3 months (severe exacerbation of regional enteritis or proximal enterocutaneous fistula and tube feeding distal is not possible, symptomatic pancreatitis). HPN therapy must also be required for at least 90 days, and weight maintenance cannot be possible using other methods (enteral feeding or pharmacological interventions).

Question 43

According to the Centers for Medicare and Medicaid Services, which of the following is an indication for home parenteral nutrition?
A. Bowel resection resulting in less than or equal to 5 feet small bowel beyond the ligament of Treitz
B. Gastrointestinal losses totaling 20% of oral intake
C. Need for bowel rest of 1-2 weeks duration
D. Failure to maintain weight on an oral diet

Answer 43

A. Bowel resection resulting in less than or equal to 5 feet small bowel beyond the ligament of Treitz

HPN is covered under the prosthetic device act of Medicare. For coverage, the patient must have documented evidence of inability to tolerate feeding through the enteral route. Typically, HPN is covered for patients with less than or equal to 5 feet of small bowel beyond the ligament of Treitz; gastrointestinal losses exceeding 50% of oral intake (2.5 to 3 liters per day in and > 1.25 to 1.5 L/day out). Bowel rest is required for at least 90 days and 20-35 calories per kilogram (kg) per day is prescribed. Other aspects of HPN require specific justification such as: calorie prescription outside the range of 20-35 calories per kg per day; protein outside the range of 0.8-1.5 grams per kg per day; and lipid use greater than 1500 grams per month.

Question 44

Which of the following is true regarding parenteral nutrition (PN)-associated metabolic bone disease?
A. Cyclic PN reduces the risk of developing metabolic bone disease
B. Excessive dietary protein may lead to a positive calcium balance
C. All patients on PN for longer than 1 year should be recommended for dual-energy x-ray absorptiometry
D. Adequate supplementation of calcium and phosphorus is achieved with PN

Answer 44

C. All patients on PN for longer than 1 year should be recommended for dual-energy x-ray absorptiometry

Receiving long-term HPN may develop metabolic bone disease. This is multifactorial including: pre-existing disease, malabsorption, metabolic acidosis, steroid therapy, inactivity, mineral deficiencies (Ca+, PO4, Mag) and Vitamin D deficiency or excess. Bone mineral testing (DEXA) should be done annually.

Question 45

Third-party payors (insurance companies) are LEAST likely to reimburse which of the following home enteral nutrition expenses?
A. Feeding bags and tubing
B. Enteral feeding pumps
C. Enteral formula
D. Intravenous poles and/or syringes

Answer 45

C. Enteral formula

Financial concerns are a strong contributor to stress in the specialized nutrition support patient. It is vital for the patient and health care providers to understand the benefits provided by the patient’s insurance coverage to ensure compliance with reimbursement and to contain the cost of treatment. Many third-party payors equate the costs of enteral formulas to “ groceries” and do not cover this expense, while they will cover the costs of an enteral pump and supplies. If the patient cannot afford the cost of the formula, the dietitian may be able to recommend an alternate formula or store brand that is less expensive. Other options for financial assistance include nonprofit organizations or indigent care programs. Formula is covered under Medicare Part B, but the patient will be financially responsible for 20% of the Medicare approved amount. If the patient has a supplement or secondary insurance, it will usually pick up the 20% that Medicare does not cover.

Question 46

Serum conjugated bilirubin level is elevated in an adult patient with short bowel syndrome. The patient has been receiving a 12-hour cycle of 3-in-1 home parenteral nutrition (HPN) solution. The clinician’s initial plan may include
A. removal of all trace elements from HPN.
B. increasing lipid calories to prevent essential fatty acid deficiency.
C. evaluation for possible overfeeding of dextrose and/or intravenous fat emulsion.
D. addition of carnitine and choline to the HPN.

Answer 46

C. evaluation for possible overfeeding of dextrose and/or intravenous fat emulsion.

Parenteral nutrition associated cholestasis (PNAC) is a condition of impaired secretion of bile or frank biliary obstruction that occurs predominately in children, but it may also occur in adult patients receiving long-term PN. PNAC typically presents as elevated alkaline phosphatase, gamma-glutamy transpeptidase and conjugated (direct) bilirubin concentrations with or without jaundice. An elevated serum conjugated bilirubin (eg >2 mg/dL) is considered the prime indicator for cholestasis. Clinical studies suggest that the development of liver complications is primarily due to excessive energy intake from dextrose and/or intravenous fat emulsion. Manganese and copper may become elevated in patients with cholestasis because they are excreted via the biliary tract. Although the dose of manganese and copper may need to be reduced or eliminated, the removal of all trace elements is not warranted. After other causes of liver dysfunction have been addressed, carnitine may be added to PN if a deficiency exists. However, the role of carnitine in the prevention of PNAC in adults has not been established. Choline deficiency also may be related to the development of PN-associated liver dysfunction, but there is no commercially available injectable choline preparation and benefits of supplementation have not proven.

Question 47

The maximum hang time an open system enteral feeding formulation container in the home setting is
A. 6 hours.
B. 12 hours.
C. 18 hours.
D. 24 hours.

Answer 47

B. 12 hours.

Open system enteral feeding containers should have a hang time of no more than 12 hrs at home and 8 hrs in the hospital. Open system enteral feeding containers are more likely to be exposed to contaminants. Closed system enteral feeding containers have a longer hang time of up to 24-48 hrs.