Nutrition care + EN Flashcards
1
Q
What is the estimated energy requirement for an obese ICU patient?
A
11-14 kcal/kg is the estimated requirement for an obese patient for BMI 30-50
2
Q
What is the 1st step in Nutrition Care process?
A
Nutrition Assessment-> identifies PES
3
Q
What should the intervention address?
A
The root cause
4
Q
What are the first steps of assessment? What questions should you ask?
A
- What is patient’s BMI?
- What is patient’s % weight change?
- Is patient’s weight loss meaningful?
5
Q
Chronic vs acute illness
A
chronic is a disease or condition that lasts 3 months or longer)
6
Q
Why would we rather use the term Inadequate oral intake vs Malnutrition for diagnosis?
A
- reserve using Malnutrition term to cases when you have actually performed malnutrition assessment (STA) - malnutrition is complex; there’s no clear definition
makes it hard for us to resolve this diagnosis - aim to use inadequate intake
7
Q
Which guidelines to use to decide whether weight loss was significant?
A
ASPEN Guidelines: identification and documentation of adult malnutrition
8
Q
WHat are the assessment and screening tools for malnutrition?
A
Screening tools: Canadian Nutrition Screening Tool
Assessment tools: Subjective Global Assessment
9
Q
Define malnutrition
A
An unbalanced nutritional state (both over and undernutrition) that alters body composition and diminishes function
10
Q
How can changes in demands that lead to malnutrition be met?
A
Food
Oral nutritional supplements
Nutrition Support
11
Q
Screening vs Assessment tools
A
Screening- anyone can use it
Assessment - used by specific professionals
12
Q
Which two components have to be present when diagnosing malnutrition?
A
- Etiology (e.g., poor food intake and/or disease burden) aka cause
- Phenotype (e.g., weight loss, low lean mass)
13
Q
Common nutrition diagnoses (problems) requiring nutrition support
A
Inadequate energy intake, inadequate oral intake, inadequate protein-energy intake
Increased nutrient needs
Malnutrition, underweight, or unintended weight loss
Swallowing difficulty
Altered GI function
Impaired nutrient utilization
Self-feeding difficulty
14
Q
What is the 1st line of treatment for malnutrition?
A
- Always food first: diet modification and food fortification
15
Q
What happens if food doesn’t work as 1st line of treatment?
A
Then aim for oral nutrition supplements (ONS)
That doesn’t work-> EN or PN
16
Q
How to decide when EN is appropriate?
A
- If GI is working, refrain from using EN
17
Q
Why should we always try to use GI when its functioning?
A
Maintain functional integrity of gut
Maintain gallbladder function
Efficient nutrient utilization
Prevents bacterial adherence and translocation
18
Q
What is trickle feeding?
A
Trophic feeding is the practice of feeding minute volumes of enteral feeds
trophic/trickle feeding continuously stimulates the gut, keeping it healthy and reducing the risk for bacterial translocation
19
Q
Contradictions of EN use
A
Severe short bowel (<100-150 cm small bowel in
absence of colon or 50-70cm small bowel in presence of
colon) - nutrition cannot be absorbed well in this case as the bowl isn’t working
Diffuse peritonitis (inflammation and infection of
peritoneal lining)
GI bleeding
Distal high output GI fistula
Intestinal obstruction or ileus
Intractable vomiting or diarrhea not responsive to
medical tx
20
Q
How is blood flow and EN connected
A
Patient has to be hemodynamically stable for EN use
ASPEN defines unstable as:
Mean arterial blood pressure of less than 50mmHg
Starting vasopressors or require increased dose to maintain BP
21
Q
When should EN be initiated when oral intake has been inadequate?
A
Different guidelines:
ASPEN: can wait 7-14 days if well-nourished
ESPEN, disease specific: E.g., in surgery, if unable to eat for more than 5 days perioperatively or cannot maintain
intake above 50% for 7 days.
British Society of Gastroenterology: absent oral intake or
expected to be absent for 5-7 days for well-nourished; earlier in malnourished.
22
Q
Summary: IS EN appropriate?
A
- Nutrition diagnosis fits
- Patient has had inadequate intake or expected to have inadequate intake for extended time (Reference guideline)
- You have tried food and food fortification
- You have tried ONS
Food/ONS is not an option (e.g., unsafe swallow) - EN is NOT contraindicated for your patient
- Patient is hemodynamically stable
23
Q
EN starting point: short vs long term (+ what is considered short and long?)
A
<4-6 weeks = short-term -> : Starts in nose or mouth
>=4-6 weeks long-term-> Starts in stomach or intestine
24
Q
Short-term EN:
- naming principle + examples
A
- EN named by where the tube enters the body and where the tip is located
EXAMPLES
- Nasogastric (NG) : nose (tube enters)/stomach (tip located)
- Orogastric: mouth (tube enters)/stomach (tip located)
- Nasointestinal: nose (tube enters)/intestine (tip
located)
25
What are the two types of nasointestinal EN?
ND (nasoduodenal)
| NJ (nasojejunal)
26
Loing-term EN:
| - naming principle + examples
Referred to by location of the tip of tube followed by suffix "ostomy"
- Gastrostomy (G-tube)- into stomach, such as PEG
- Jejunostomy (J-tube)- into jejunum, such as PEJ
27
How is ostomy created?
Ostomy created two ways:
- Surgical gastrostomy (requires anaesthesia)
- PEG- percutaneous endoscopic gastrostomy (placed without a surgical incision using an endoscope) - (no anaesthesia)
28
Feeding into stomach vs intestine
People tolerate stomach feeds better than intestine
29
Why would we feed into intestine when stomach feed is better tolerated?
Contraindication to gastric feeding or GI needs to be bypassed
- Gastroparesis (delayed gastric emptying)
- Severe acute pancreatitis
- Recurrent aspirations
- Gastric or proximal small bowel obstruction
- Proximal enterocutaneous fistula but jejunal access possible below fistula
- Significant gastric compression for any reason e.g. tumor
- Gastric feeding intolerance
30
Standard or polymeric formulas provide __kca/ml and approx. __% protein
Standard or polymeric formulas provide 1kca/ml and approx. 10-15% protein
31
What are the 3 types of formula?
1. Standard,polymeric
2. Elemental/ semi-elemental
3. Disease-specific
32
Describe polymeric formulas
Contains intact protein, carbohydrates and long chain
triglycerides
Most of the patients need this type of formula
33
Describe elemental/semi-elemental formulas
- Contains completely or partially digested nutrients; proteins
as free amino acids or peptides, simple sugar and glucose
polymers, and fat, primarily MCT
- Often used with J-tube feedings as they skip the stomach thus no digestion
34
Describe disease-specific formulas
Designed to meet the needs of patients with specific diseases, such as diabetes, renal, pulmonary, immune- modulating and liver diseases.
35
Describe typical soy or casein-sourced protein in EN formulas
intact proteins
Requires enzyme function in the patient
10-15% kcal as protein for standard formulas (which is not enough on sick patients)
36
Describe hydrolyzed, semi-elemental, elemental protein in EN formulas
Peptides
| Used in patients with malabsorption/maldigestion, enzyme deficiency
37
Describe Specialized amino acid profiles protein in EN formulas
Used for inborn errors of metabolism e.g. PKU
38
Describe CHOs in EN formulas
Source: monosaccharides (glucose), oligosaccharides, dextrins, maltodextrins
Most lactose free and gluten-free
May contain fructo-oligosaccharides (FOS): Form of prebiotic-> ferment to SCFA and maintain GI integrity Fiber free, low residue, or fiber added-> add fiber in long-term patients
39
Describe lipids in EN formulas
- Source: Corn and soybean oil most common long- chain triglycerides (LCT)
- Safflower, canola, and fish oil also used
- Palm and coconut may be added as a source of MCT
- MCT don’t have enough essential FA-> they need to be added
40
What should be remembered about vitamins/Minerals in EN formulas
- Formulas should meet DRIs for adults (typically if 1500ml/d delivered)
- Supplemental formulas are required for wound healing and stress
- Most importantly: Compare pt needs to amt provided in formula
41
What are the classes of formulas in terms of caloric density
- Ranges: 1.0 - 2.0 kcal/mL
- Standard is 1kcal/1ml
- 1.5-2.0 kcal/mL are considered nutrient dense
42
Why would you want a nutrient dense formula?
- High caloric needs
- Patient unable to tolerate large volumes of fluid: impaired renal, cardiac, pulmonary function
- Restriction on EN delivery volume e.g. too much food makes them throw up
43
Describe osmolarity of Hydrolyzed and elemental formulas
Hydrolyzed and elemental not iso- osmolar. Usually have higher osmolality.
44
is formula a common cause of diarrhea?
Hyperosmolar may cause diarrhea, but likely the meds NOT feeds
45
Predictive equations using the "Rule of Thumb" kcal/kg
Underweight: 35 kcal/ kg Actual body wt (ABW)
Normal weight: 30 Kcal/kg ABW
Overweight: 25 Kcal/kg ABW
Obese: 11-14 Kcal/kg ABW 22-25 Kcal/kg IBW (BMI)
46
Rule of Thumb for fluid requirements
```
1kcal/ml
18-55 y: 35 ml/kg
56-75 y: 30 ml/kg
>75 y: 25 ml/kg
Fluid restriction: <25 ml/kg (renal, cardiac, fluid overload)
```
47
Describe bolus feeding
- 250-500 ml several times a day
- Gravity feed (ie no pump) or syringe injection
- Not well tolerated in medically unstable pts
- Often used for home tube feedings or pt in long-term care
- Usually least expensive option
- usually 4X/day
- less restrictive and complicated
- simulates a meal
48
How does the rate of gravity flow change depending on the position of the syringe?
syringe or bag
if syringe is held closer to the body, the rate will be faster
syringe and gravity feeds are not administered at specific rate, they just drip
49
Describe intermittent feeding
- Usually uses a pump to control delivery rate
- Lg volumes given several times a day but over 20-30 minutes
- not hooked up 24/7
- given into the stomach or intestine
- may be given to the patients
who were not tolerating bolus feed well due to the amount
- suitable for: long-term care, going home, PEG/PEJ
50
jejunum feeds are usually given through the __as t__
jejunum feeds are usually given through the pump as they are not tolerated in the gravity form
51
Describe continuous feedings
- Given 24 hrs or cycled over 8-12 hrs
- Uses a pump
- Improves feeding tolerance but very restrictive
- Preferred in acute care setting- maximal GI tolerance
acute
any feed can be given continuously
well tolerated-> used in the hospitals
52
What are the types of equipment used for EN?
- Feeding tubes: Lumen diameter described using a measurement called French size (1Fr = 0.33cm). Range 10-14Fr
- Pumps
- Syringe
53
EN Protocol: Advancement
Note: Protocols vary with institution
Always assess for refeeding risk first: prolonged NPO,
starvation, severe malnutrition
Recommendations for initiation of continuous EN generally start at 20-50mL/hour, and advance by 10-25mL every 4-24 hours as tolerated.
If a 2.0 kcal/mL is used, EN is typically started at 25-30mL/hr.
usually we start at continuous
but if you know that the patient will go home, start them on intermittent
start with 125ml/h, advance by extra 125ml/feed until the goal is reached
don’t start on bolus, as it is not well tolerated
54
What is GI intolerance
Vomiting, abdominal distention, complaints of discomfort, high NG output, high gastric residual volume, diarrhea, reduced passage of flatus and stool, or abnormal abdominal radiographs
55
What are the recommendations for EN termination?
Encourage oral intake (if acceptable e.g. noswallowingn problems)
May need to try cyclic feeds (e.g., continuous for 8 hours overnight) to encourage PO during the day.
Guidelines for PO adequacy vary.
ESPEN, surgery: >50% energy needs consistently met with PO, can terminate.
56
EN Protocol: Flushes
Flushing - Required to ensure tube patency
GENERAL GUIDELINES:
1) Flush enteral feeding tubes every 4-6 hours with 30-60ml, or prescribed amount, of lukewarm water during continuous feeding and before and after intermittent/bolus feedings
2) Flush with 30-60ml, or prescribed amount, of lukewarm water after checking residual stomach contents.
3) Flush enteral feeding tubes with 30ml, or prescribed amount, of lukewarm water after administration of medications. If administering more than one medication, flush with 5-10ml, or prescribed amount, of warm water between each medication
NOTE: Count flushes as part of fluid intake!
57
EN Protocol: Gastric residuals
Residual volume of liquid in stomach (GRV) used to determine whether a feeding has emptied. This practice was thought to be impt to determine risk of aspiration.
No longer SUPPOSED to be practiced to monitor tolerance- based on the poor sensitivity, specificity, and accuracy with which GRVs identify poor gastric emptying and predict aspiration pneumonia
Typical protocol: nursing to check gastric residuals every 4hrs with continuous feeding or before admin of bolus feeding to ensure emptying
If a residual greater than 500ml on 2 !!!consecutive!!! measures, enteral feeding should be stopped
After 48-72hrs of successful feeding, can stop GRV practice
58
Adult tube feeding intolerance algorithm
```
ABDOMINAL SIGNS
● Distention
● Firm
● Tense
● Guarding
● Discomfort
NAUSEA
● Antiemetics
● Minimize narcotics
● Check for constipation
● Notify LIP
EMESIS
● Hold feeding
● Check for constipation
● Notify LIP
```
59
Which factors might be out of range if the patient is over-fed in EN?
liver function, TG and glucose may e out of range if patient is over-fed
unlikely with enteral nutrition, more common with parental nutrition
60
Summary: Calculation of EN Prescription
1. Choose feeding route (tube)
2. Calculate nutritional needs (Kcal, Pro and fluid needs)
3. Choose appropriate formula
4. Determine administration mode (time and rate)
5. Calculate water flushes
6. Verify nutritional goals are met
7. Monitoring
61
Describe tube-related complications
nursing tracks, but you should be aware esp. if tube was halted for extended period of time.
How much nutrition did patient actually get?
Clogged? Did you provide enough water? Flushes?
62
Describe GI complications
constipation, n/v, diarrhea
Constipation: water, fibre, physical activity
Diarrhea (osmotic or infectious?): adding soluble fiber (pectin,
psyllium) may help
n/v: stop feed, determine cause
encourage physical activity-> resolves the problem
check if there is an actual blockage vs going to toilet less due to chnaes in bowel
63
Describe aspiration complications
This is rare but we need to check to decrease the risk
(increased risk of pneumonia):
Prevent by having bed at 30o angle
Residuals: stop feed if >500 ml found 2 consecutive times!!!!!!- important
If delayed gastric emptying, might need low fat, low fiber,
and/or isotonic formula; change from bolus to continuous.
64
Causes of diarrhea
Medications sorbitol based, hypertonic meds, antibiotics
Most drugs and electrolytes should be diluted
Infection C. difficile, non-clostridial bacteria
EN formulation osmolality, fat (malabsorbed), lactose?
Most standard formulations are low osmolality, not too high in fat and include MCT, and lactose free = Least likely cause; Contamination of feed.
rate of flow?
65
Questions to be asked when experiencign diarrhea
What are normal stool habits of patient?
- Any abnormal volume or consistency
What pre-existing conditions does patient have?
66
Hwo should electrolytes be administered? Why
electrolytes should be given by IV
| they are high osmolality and will cause diarrhea
67
Names of sorbitol drugs
```
Acetaminophen elixir
Cimetidine
Furosemide
Codine
Indomethacin
Metoclopramide
```
68
Managment of diarrhea
MD to R/O infections, inflammation, fecal impaction, medications
Switch medications if hypertonic or dilute in sterile water; non-sorbitol fillers or alternative medications
Change EN to lower mOsmol/L, lower fat (MCT)
Choose EN with soluble fibre
Antidiarrheal agent if not bacterial
Continue EN, use PN if prolonged
malabsorption
69
Dehydration during EN
Typically provide 1ml/kcal of fluid
Check serum osmolality, BUN, creatinine, serum sodium to
determine if adequately hydrated
70
Electrolyte imbalances during EN
IV supplementation often preferred
71
Under or Overfeeding during EN
Efforts to meet >80% of rqmt in 1st week of EN
Permissive underfeeding done to prevent metabolic and
resp complications in metabolically stressed pts
Overfeeding may cause hepatic steatosis (fatty liver), hyperTG and hyperglycemia
Stndrd delivery = 25-30 kcal/kg
Obese patient (BMI 30-50) = 11-14 kcal/kg
72
Hyperglycemia during EN
Common in metabolically stressed pts; use
| most of the patients will have hyperglycemia due to stress (not due to being overfed)
73
Common nutrition diagnoses that may necessitate alternate routes for nutrition interventions include:
inadequate energy intake, inadequate oral intake, inadequate enteral nutrition infusion, inadequate parenteral nutrition infusion, inadequate fluid intake, inadequate bioactive substance intake, increased nutrient needs, malnutrition, inadequate protein-energy intake, swallowing difficulty, altered GI function, impaired nutrient utilization, unintended weight loss, suboptimal growth rate, and self-feeding difficulty.
74
surgical gastrostomy vs percutaneous endoscopic gastrostomy (PEG)
percutaneous endoscopic gastrostomy (PEG)—a procedure used by a physician toinsert a feeding tube through the skin and into the stomach using an endoscope
surgical gastrostomy—an opening into the stomach that requires a surgical procedure
75
Which equipment is used for bolus, intermittent and continuous?
Bolus: syringe
Intermittent: pump, gravity
Continuous: pump
76
What is more common: constipation or diarrhea?
constipation
77
“ How do you assess the risk for refeeding in a patient requiring enteral nutrition (EN) therapy? How can you reduce the risk for refeeding in the enterally fed patient?”
“ Electrolyte replacement protocols are followed to replenish potassium, phosphorus, and magnesium levels on the day of admission. Electrolytes are rechecked prior to the initiation of EN and are within normal ranges.”
78
“factors that increase the risk for clogging the feeding tube”
“use of a fiber-containing formulas, use of small-diameter tubes, use of silicone rather than polyurethane tubes, checking gastric residual volumes (GRVs), and improper medication administration via the tube”
79
How can u measure adequacy of feed
“Radiographic imaging techniques, such as CT, magnetic resonance imaging (MRI), and ultrasound, are emerging as instruments to measure LBM. These tools are most beneficial in a hospital setting, where scans are already performed for the purpose of medical diagnosis
“Nitrogen balance (NB) can be used as a tool to assess adequacy of protein provision. Measurement of urinary urea is used to estimate nitrogen losses, and 24-hour urine collection is required for accurate measurement, although some practitioners have collected urine for shorter time periods and extrapolated results to 24 hours.
80
Patients with chronic kidney disease (CKD) on dialysis have increased protein needs and may require __ and __ restrictions
Patients with chronic kidney disease (CKD) on dialysis have increased protein needs and may require fluid and electrolyte restrictions
81
Which formulas are administered to people with fluid restrictions?
standard, energy-concentrated (up to 2 kcal/mL) enteral formulas that can be used instead of disease-specific formulas when the patient’s clinical condition calls for restricted volume.
82
If a nasoenteric feeding tube cannot be unclogged using water flushes, what is the next most reliable method for unclogging the tube before it is replaced?
1. Administer cola through the tube, and let it sit for a few hours.
2. Administer Clog Zapper (CORPAK MedSystems, Buffalo Grove, IL), and flush within 30 to 60 minutes.
3. Wait a few hours to see whether the clog dissolves spontaneously.
4. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1 to 2 hours (or longer), and then flush with warm water.”
“ D. Pancreatic enzyme solutions have been studied, and, in one report, this method of unclogging tubes had a 90% success rate when the tube was allowed to sit for 2 hours.
“Clog Zapper is a commercial mixture of papain, α-amylase, and citric acid solution. It has a lower success rate than pancreatic enzyme solutions. Waiting longer will not help a tube become unclogged.”
83
“Which of the following actions is most appropriate for enhancing gastric emptying during the administration EN?
a. Keep the bed in Trendelenburg position.
b. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous feeding.
c. Switch to an enteral formulation with a higher fat content.
d. Switch to an enteral formulation with a higher protein content.”
“ B. Factors that delay gastric emptying include large boluses of fluid given at one time, increased rate of formula infusion, increased fat content of the solution, and infusion of solutions colder than room temperature. Elevation of the head of the bed (HOB) and turning of the patient slightly to the right side allows gravity to help drain the stomach; however, such positions are often difficult to achieve in the hospital environment.”
84
“Which of the following is the most appropriate initial action for the management of tube feeding–associated diarrhea?
a. Change to an enteral formulation with fiber.
b. Review the patient’s medication administration record to determine whether hyperosmolar agents are being administered.
c. Change to a peptide-based enteral formulation.
d. Use an antimotility agent.”
“B. If clinically significant diarrhea develops during EN, the most appropriate initial action is to evaluate whether hyperosmolar medications that could result in liquid stooling are being administered. If none are in use, testing for the presence of Clostridium difficile; if those results are negative, the addition of fiber from a formulation that contains “fiber or supplemental fiber may be beneficial. Adding an antimotility agent or changing to a peptide-based formula should be considered if diarrhea continues despite these initial interventions. PN should be initiated only if the other treatment modalities fail.
85
If GRVs are low but nausea persists, patients may benefit from__
If GRVs are low but nausea persists, patients may benefit from antiemetic medications.
86
WHat are the signs of maldigestion?
bloating, abdominal distention, diarrhea
87
What are the common causes of diarrhea in EN patients?
medications, bacterial infection, GI disease,
“Characteristics of the formula (osmolality, fat content) and specific components in the formula (eg, lactose) are less likely to cause diarrhea
“Antibiotic-associated diarrhea (AAD) is a common medication effect
88
“Risk Factors for Refeeding Syndrome
```
Malnutrition
Inadequate nutrition intake for >2 weeks
Poorly controlled diabetes
Cancer, both before and during treatment
Anorexia nervosa
Short bowel syndrome
Inflammatory bowel disease
Being an older adult living alone
Low birth weight and premature birth
Chronic infections (eg, HIV)
```
89
Is hyperglycemia more associated with EN or PN
PN
