nutrition support Flashcards
1
Q
what are the routines of nutrition support? 3
A
- Food first- safest, cheapest and most acceptable
- If restricted to fluids or not eating enough- oral nutrition supplements
- Unless it is contra-indicated- unsafe swallowing, damaged/ non-functioning gut
2
Q
what do we do when oral nutrition is unsuccessful? 5
A
- Unsafe swallowing
- Unable to eat enough despite oral nutrition supplements
- Enteral= using the gut
- Unless contraindicated- damaged/ leaking/ short/ atonic/ obstructed gut
- Parenteral= bypassing the gut
3
Q
describe enteral nutrition? 6
A
- Nutritionally complete liquid feeds through various tubes which access the gut
- Use if the gut is functioning
- Unable to swallow- includes unconsciousness
- Insufficient oral intake despite supplements
- Unable to tolerate supplements
- Patient choice
4
Q
describe parenteral nutrition? 8
A
- Nutritionally complete liquid feed which is broken down to glucose and amino acids and fats, and engineered to be safely administered intravenously
- Us if the gut is not functioning
- Aperistaltic
- Obstructed
- Too short (most always when less than 100cm of small bowel is remaining)
- Too damaged
- High fistula
- Inaccessible
5
Q
describe the different options for the enteral nutrition tubes? 3
A
- Route of access: nasal vs percutaneous
- Where the feed is being delivered: gastric vs jejunal
- How the access was put in: endoscopic vs interventional radiology
6
Q
what are the advantages for naso-gastric tube feeding? 5
A
- Uses the gut- physiological
- Fast and easy to pass tube- can be done bedside by most nursing staff
- Minimally invasive
- Generally, well tolerated
- Easy to remove if no longer tolerated or required
7
Q
who is naso-gastric tube feeding suitable for? 6
A
- Working gut
- Stomach emptying (into the duodenum)
- Safe to put tube down the nose and oesophagus
- Patient must accept and tolerate the tube
- Short-term feeding (up to 8 weeks)
- Can be used for unconscious patients on ITU, post op, post stroke, acute illness
8
Q
what are the risks for naso-
gastric tube feeding? 3
A
- Tube misplaced/ displaced/ blocked
- Reflux/ aspiration
- Not tolerated- tube itself or volume of feed infused
9
Q
how do we confirm correct placement of a naso-gastric feeding tube? 5
A
- The chest x-ray view should be adequate- upper oesophagus down to below the diaphragm
- The NG tube should remain in the midline down to the level of the diaphragm
- The NG tube should dissect the carina (T4)
- The tip of the NG tube should be clearly visible and below the diaphragm
- The tip of the NG tube should be several cm (10) beyond the GOJ to be confident that’s it’s within the stomach
10
Q
what is the NG care bundle? 3
A
- Safety checklist
- Aimed at avoiding feeding trough a misplaced tube
- Lots of documentation required to assure adherence to the care plan
11
Q
what are the advantages of naso-jejunal feeding? 4
A
- As for NG feeding and
- Vomiting/ gastroparesis/ duodenal obstruction
- Minimally invasive, although may need an x-ray of endoscopy to place
- Less likely to aspirate/ get misplaced
12
Q
what are the risks of naso-jejunal feeding? 5
A
- Technically difficult
- Generally, needs endoscopy or placement in interventional radiology
- This can create delay in feeding
- Risk of mis/ displacement
- May still not be tolerated
13
Q
what do PEG and RIG stand for?
A
- Percutaneous endoscopic gastrostomy (PEG) or radiology inserted gastrostomy (RIG)
14
Q
what are the advantages of PEG? 3
A
- Uses the gut/ physiological
- Durable- tube can last up to a couple of years and is unlikely to be accidently displaced
- No tube in the throat or on the face- comfort and cosmetic
15
Q
who is PEG suitable for? 5
A
- Functioning gut
- Inability to swallow adequate food/ fluid
- Due to irreversible or long-lasting cause
- In whom nutrition support is thought to be appropriate
- Who can tolerate an endoscopy and minor surgical procedure?
16
Q
what are the risks and shortcomings of PEG? 11
A
- Perforation
- Sepsis (peritonitis and skin infection)
- Bleeding
- Perforated viscous
- Attached to pump 20 hours a day
- Misplacement
- Reflux
- Buried bumper
- Death
- Not involved in mealtimes
- alteration in body image
17
Q
how can we get percutaneous jejunal access?
A
- surgical jejunostomy
- PEJ
- RIJ
18
Q
what are the advantages for PEJ/RIJ? 3
A
- As for PEG
- Tolerated if gastroparesis/ duodenal obstruction
- Long-term option for those needing NJ feeding
19
Q
what are the risks for PEJ/RIJ? 3
A
- As for PEG
- Tolerated if gastroparesis/ duodenal obstruction
- Long-term option for those needing NJ feeding
20
Q
what is total parenteral nutrition? 7
A
- Fluid
- Electrolytes
- Protein as amino acids
- Fat
- Carbohydrates
- Vitamins
- Minerals
21
Q
how is TPN administered?
A
central line
22
Q
what are the problems with TPN? 7
A
- Line access complications= misplaced line, extravasation of TPN, clot on the line (thromboembolism), line infection
- Hyperglycaemia
- Fluid/ electrolyte disturbance
- Over/ under feeding
- Liver disease
- Gut not being used= atrophy and inflammation
- Expensive
23
Q
how do we monitor TPN? 3
A
- 4 hourly observations including temperature and blood glucose
- Daily U&E, Ca2+, phosphate, LFT, FBC, line inspection and weight check
- Monthly check on micronutrients and triglycerides
24
Q
what are refeeding syndromes? 4
A
- Severe electrolyte and fluid shifts
- Associated with metabolic abnormalities
- In malnourished patients undergoing refeeding
- Whether orally, enterally or parenterally
25
what is the pathogenesis of refeeding syndromes? 7
- During starvation energy is saved by switching on trans membrane pumps
- Na (and water) drift intra-cellularly
- K and phosphate drift extra-cellularly (and are excreted to keep plasma levels stable)
- This leads to total body depletion
- As soon as you get any energy, these are all switched back on immediately
- Sudden drop in plasma K and phosphate arrhythmias
- Sudden surge in plasma Na and water overload
26
how do we avoid/ treat refeeding syndrome? 5
- Be aware of the risk
- Check electrolytes
- Begin replacement before feeding
- Start slow and build up
- Keep monitoring electrolytes daily and replacing as necessary
27
what is Wernicke- Korsakoff’s syndrome? 7
- WKS is a neurological disorder
- Wernicke’s encephalopathy and Korsakoff’s psychosis are the acute and chronic phases of the same disease
- Caused by a deficiency in the B vitamin thiamine and is most frequently seen in alcoholics
- Precipitated by providing calories in the absence of sufficient reserves of thiamine- by refeeding
- Wernicke’s= ophthalmoplegia, unsteady gut, nystagmus, confusion
- This is reversible but only if you act quickly to give IV thiamine
- Korsakoff’s psychosis= sudden onset, dramatic, irreversible, memory loss, confabulation
28
how do we treat Wernicke- Korsakoff’s syndrome? 5
- Be aware of the risk
- Replace thiamine before and during refeeding
- If low risk and able to eat, use high dose oral thiamine
- If high risk or not eating, use IV pabrinex
- Banana bags
29
what is the best supportive care for malnourished people? 3
- Oral nutrition supplements
- Oral hydration
- Antiemetics
30
what is the significance of feeding? 4
- Basic care
- Procedures are essential to keep an individual comfortable
- Includes warmth, shelter, pain/ symptom relief, hygiene measures and the offer of oral nutrition and hydration
- Appropriate basic care should always be provided unless actively resisted by the patient
31
describe a doctors duty of care and providing nutrition? 3
- When artificial nutrition and hydration is necessary to keep the patient alive, the duty of care will normally require the doctors to keep supplying it
BUT…
- If feeding requires medical intervention and is not thought to be providing benefit, then there may be circumstances in which is should not be done
- A discussion of benefit vs risk needs to be had with the patient and their family
32
how could PEG be a benefit?
- Improved life expectancy
- Improved quality of life medication can be given for symptoms of pain, increase and maintenance of weight and improvement of healing (pressure ulcers)
- Improved daily activities increased capacity for rehabilitation
