Seminar #5 Enteral Feeding Flashcards
1
Q
top to bottom, right to left
GI/GU assessment regions
A
right hypochondriac –> epigastric region –> left hypochondriac region
right lumbar –> umbilical region –> left lumbar
right iliac region –> hypogastric region –> left iliac region
2
Q
what do you hear?
audible abdominal vascular sounds
A
bowel sounds + abdominal bruits
e.g., aortic aneurysms, “shuu-shuu-shuu-shuu”
don’t always indicate disease, could be heart murmur transmitted to abdomen
3
Q
what is enteral nutrition?
A
- administration of nutrients directly into gastrointestinal tract
- preferred method for providing nutrition and should be used when pt’s GI tract is functional
- considered advanced directive, can have ethical implications
4
Q
Malnutrition S/S
A
- mental confusion, irritability; inability to concentrate; apathetic; listless
- lack of appetite + disinterest in food
- changes in skin colour
- dry, scaly skin; brittle, pale nails; dry, dull, sparse hair
- swollen + bleeding gums; decaying teeth
- eyes dry, sunken; cheeks hollow
- fatigue, low E; muscle weakness
- distended abdomen; enlarged liver
- weight loss, muscle wasting
- poor immune function; infections; poor wound healing
5
Q
Abnormal blood results in malnutrition
A
decr:
- albumin, prealbumin, total protein
-Hgb/Hct (if anemic)
- iron/ components
- lymphocytes / incr if infection
- bld glucose
- K+ & calcium + other lytes
- BUN & CR
- serum vitamin + mineral levels
6
Q
why are liver enzymes increased in malnutrition?
A
body starts using liver when there isn’t enough nutrients –> body breaks liver = incr liver enzymes
7
Q
pros & cons
Enteral vs Parental
A
parental: fails to stimulate gut resulting in
- villous atrophy
- loss of gut mass
- compromising physical barrier (decr SA)
enteral: maintains gut mass, function + integrity
8
Q
What is early feeding associated with?
A
- decr length of stay
- decr infection/ sepsis
- incr nutrition goals
- improved nitrogen balance
9
Q
How is enteral feeding given?
A
via stomach or intestine
- do NOT give in blood – will be FATAL
10
Q
how is parental feeding given?
A
via IV through central vein
11
Q
indications for Enteral Feeding
A
- functional + accessible GI tract
- malnourished/risk of malnutrition
- to supplement food intake when it’s insufficient to meet daily needs
- unable to ingest oral foods, e.g., surgery, head/neck trauma
- unwilling to take oral feeds (prolonged anorexia)
- upper GI tract impaired (eso ca)
- dysphagia (CVA, MS, ALS)
- critical illness (severe burns)
- malabsorption disorders (Crohn’s)
- decr LOC, coma
12
Q
indications for parental feed?
A
non-functioning GI tract
- admin via central vascular access device (CVAD) & often PICC = preferred route
13
Q
contraindications for enteral feeding
A
- no gag reflex / airway needs to be protected w/ artificial airway
- GI tract not functioning (e.g., intestinal obstruction, ileus bowel fistula)
- not able to elevate HOB during feeds (e.g., back/neck injury unless can tilt bed)
14
Q
Enteral feeding complications
A
-** refeeding syndrome**
- aspiration
- metabolic problems (e.g., deficiency /excess lytes, vits, trace elements, h2o)
- over-hydration
- hypo/hypernatremia
- tube dislodgement
- infection
- GI side effects (nausea, abdo bloating, cramps, regurgitation, diarrhea, constipation)
15
Q
how to avoid refeeding syndrome?
A
feeds should be started slowly, and lytes closely monitored + adequately replaced to avoid development
16
Q
What is refeeding syndrome?
A
malnourished pts fed w/ high carbohydrate loads
- causes large incr in circulating insulin level –> rapid + dramatic fall in PO4, K+, Mg2+ + incr ECF volume
- incr in o2 consumption, RR + cardiac workload
- demand outstrips supply
- return of enteral feeding after starvation-induced gut atrophy can lead to intolerance to feed, n/d
17
Q
What can starvation lead to?
A
-multiple organ failure
- respiratory and/or cardiac failure
- arrhythmias
- rhabdomyolysis
- seizures or coma
- rbc/leukocyte dysfunction
18
Q
Enteral feed complication
Pulmonary aspiration - what to watch for?
A
incr SOB, productive cough, sputum, difficulty swallowing
- assess gag reflex, temp, HR, RR
19
Q
Enteral feed complication
Pulmonary aspiration - how to prevent
A
ensure HOB elevated while continuous feed is running, and for 1h following intermittent feeds
20
Q
Aspiration risk factors (for all feeding tubes)
A
- HOB less than 30 degree angle
- impaired LOC (e.g., sedation)
- neurological deficits
- poor oral health
- mal-positioned feeding tube
- gastroesophageal reflex
- age over 60 years
- delayed gastric emptying
21
Q
Treatment for aspiration
A
- STOP tube + notify MRP
- lower HOB & put pt on left side to prevent further seepage of formula into lungs
- suction as necessary
- monitor O2 sat + admin o2 if needed
- anticipate cxr order
22
Q
Short-Term feeding tubes
A
less than 4-6 weeks
- nasogastric tubes (hard bore, soft bore)
- naso-enteric tubes (naso-duodenal, naso-jejunal)
23
Q
ST Feeding tubes
What are nasogastric tubes?
A
inserted into nostril down into stomach
- req intact gage + cough reflex, or airway protected
- must have adequate gastric empyting
- hard bore or soft bore
24
Q
ST EF
Hard/large bore NG Tube:
Salem + levin
A
- changed** weekly**
- often used w/ anti-reflux valve
- salem sump
25
Salem sump - hard bore NG tube
larger tube, double lumen (main tube/smaller air vent lumen), w/ holes near tip
- usually 12-18 FR diameter
- may be used for suction bc smaller vent lumen allows for inflow of air which prevents vacuum if tube adheres to stomach wall
- larger lumen connects to suction for drainage of gastric contents
26
Levin - hard bore, NG tube
levin (less common):
- single lumen connects to suction
27
What is anti-reflux valve?
- prevents gastric reflux or leakage through the vent lumen of a double-lumen nasogastric tube
- valve allows passage of air into vent lumen when atmospheric pressure exceeds stomach pressure
- when stomach pressure exceeds atmospheric pressure, valve prevents flow of fluids through the tube
attach by connecting "blue end" of reflux valve to "blue vent" opening
28
ST Enteral Feeding - Naso-Enteric Tubes
Naso-duodenal + naso-jejunal
- longer than nasogastric tube (40cm or >), e.g., jejunum is 25cm (10") from stomah
- inserted into upper small intestine
- usually greater dilution + smaller volumes
- for pts of aspiration risk
28
Soft bore (small) NG tube
e.g., levin
- most common for enteral feeding in IH
- usually 6-12 FR diameter
- smaller, more flexible, less irritating
- may have weighted tip
- have stylet to assist insertion - removed afterwards
- changed **monthly**
29
Nasal tubes complications
- aspiration
- misplacement of tube
- nasal pharyngeal irritation + pain
- sinusitis, sore throat, epistaxis
- perforation (lung, esophagus, stomach, SI) - but rare
- inadvertent lung placement (pulmonary injury)
- intracranial placement (e.g., head trauma)
29
Naso-enteric tubes indications
risk of aspiration:
- decr LOC
- poor or absent cough/gag reflexes
- endotracheal intubation
- recently extubated
- inability to cooperate w/ procedure
- restlessness or agitation
29
LT feeding tube indications
meets both:
- inability to meet nutritional needs orally
- death isn't imminent
one of the following:
- over 4-6 weeks on nasogastric and/or orogastric feeds
- low probability of nutritional needs met orally over next 4-6 weeks
- nasogastric tube placement contraindicated
30
LT Feeding Tubes
- Gastronomy Tube / Jejunostomy tube (G-tube/ J-tube)
- percutaneous endoscopic gastromy (PEG) tube & Percutaneous endoscopic jejunostomy (PEJ) tube
30
Gastrostomy tube or jejunostomy tube (G-tube / J-tube)
- inserted thru abdominal wall into stomach / jejunum
- usually for > 6-8 weeks
- placed surgically or by laparoscopy thru abdo wall into stomach/jejunum
- larger abdo incision
- usually longer NPO time b4 starting feeds
31
PEG tube or PEJ tube
- for > 6-8 weeks
- use endoscopy to visualize inside of stomach, making puncture through skin & inserting tube thru puncture
- smaller abdo incision
- shorter NPO time (often start feeds by 24h)
- have catheter w/ external bumper
- internal inflatable retention balloon to maintain placement
32
Low profile feeding tubes?
may be secured w/ bumper or balloon
- J-tube -- balloon sits in stomach, end is floated into small bowel, peristalsis keeps it in place
button peg -- for peds, sits there, attaches extension tube when feeding
33
# LT enteral feeding tubes
How to decide G-tube or PEG Tube?
- G-tube can be placed endoscopically, surgically, or radiologically
- procedure choice would be based on local resources, expertise + anatomical considerations
- PEG tube less expensive + saves time
- surgical gastrostomy reserved for pts already going to operating room for another procedure
- surgical gastrostomy also for pts where tube can't be placed endo/radiologically
e.g., esophgeal obstruction; presence of anatomic aberration that prevents safe percut approach for PEG tube placement; inability to endoscopically identify appropriate placement site bc prior surgery/obesity
34
G/PEG and J/PEJ tube complications
- peristomal infection
- leakage
- accidental tube removal
- tube blockage
- tube fracture
- tube displacement
- peritonitis
- aspiratoin pneumonia
- bleeding
35
when to do LT feeding tubes ballon volume check?
don't check for first 4 weeks after insertion
after 4 weeks, check weekly/per policy
- use slip tip syringe
- remove all old h2o, measure, and discard
- draw appropriate h2o & re-inflate to prescribed level
36
What to do if LT feeding-tube falls out?
cover site w/ sterile gauze & notify MRP / NP asap
- don't re-insert any tube into stoma --> can result in perforation injury, mal-position, or formula entering SC tissue/peritoneal cavity
37
Closed/ Continuous Drip Feeding systems
- usually used initially whe pt doesn't tolerate bolus
- 1000-1500 mL container
- hang-time up to 48h (if sterile techniqe used)
- may be administered @ night (nocturnal feeds) so pt can try to eat during day
- essential when feedings are administered into small bowel
- tubing change w/ bag change; up to q48h
- usually run using pump
- always start slow & incr as tolerated
37
Open system/ Bolus or intermittent feed
| Feed systems
- for when pt able to tolerate bolus feets
- 250 mL tetra packs or cans; dry powder
- usually 300-500 mL given several times/ day (e.g., breakfast, lunch, supper, bedtime)
- admin over at least 30 mins
- must be given only in stomach (monitor for aspiration + distention)
- may use feeding pump, gravity drip, or syringe (w/o plunger)
- bags + tubing need to be rinsed w/ tap h2o, drained, and hung to dry following intermittent feeds
38
what to label feeding systems with
client info, date/time, preparer's intitials, enteral feeding formula type, rate, strength, and amount
- label cloes to pt & @ site close to source when there are diff sites/bags
- label admin set "tube feeding only"
39
what's needed for enteral feeding?
- 60 mL leur-lock syringe + container for h2o (flushes)
- 35mL syringe for med admin
- sterile bowl if needed
- ENFit attachment (connectors, stopcocks, or valves)
40
Cleaning ENFit connection system
- clean moat + cap of feeding tube q24h + prn
- replace cleaning tool q24h
40
Enteral Feeding Formulas
standard formula provides 1kcal/mL of solution w/ protein, fat, carb, minerals, vits in specific proportions
41
what enteral feeding formulas are available
- low volume
- high fibre
- high protein
- low sugar/CHO
- high nitrogen
- w/ fibre for treatment of diarrhea
- predigested + easy to absorb (Osmolite HN)
- natural formual (new)
42
Enteral Formual hang times
- tetra pack (ready to use): 8h
- reconstituted powder: 4h
- closed system formula bottles: 48h
43
when to change feeding bags/tubing/accessory equipment?
- open system: q24h
- closed system: q48h or when bag empties, whichever is first
- accessory equipment: q24h (syringes, bowls, cups, etc.,)
- attachments: weekly (stopcocks, valves)
44
what is the most accurate way to confirm the placement of a NG tube used for feeding?
through cxr / xray
44
Nursing care prior to starting tube feed
- check MAR, PPO for type of feeding tube, solution, and h2o flushes
- check xray report + MD written order verifying tube placement
- determine if pt at risk for refeeding syndrome
- **review nutritional assessment**
- **review recent labs**
- check last weight recorded
45
Registered dietician role in enteral feeding
consulted for all pts w/ enteral feeding
determines enteral feeds + h2o flushes:
- total free h2o requirement
- total caloric requirement
46
what is total free water requirement?
amount of fluid pt needs in 24h period to sustain life
- enteral formulas contain 60-85% h2o
- need to supplement feeds w/ h2o
47
What labs are ordered for tube feeds?
baseline: CBC, lytes, urea, creatinine, random glucose, ionized calcium, phosphorus, magnesium, albumin
daily x 3 days: lytes, urea, creatinine, random glucose, phosphorus, magnesium
weekly q monday x 3 weeks: cbc, lytes, urea, creatinine, random glucose, ionized calcium, phosphorus, magnesium, albumin
48
enteral feed: Rate of administration - standard feed
initiate Isosource 1.2 @ 25mL/H
- if tolerated, increase at 8H to 50 ml/H
49
# For enteral feed
Rate of administration for refeeding syndome risk?
- isosource 1.2 at 25 mL/H for minimum of 24h
- don't advance until K+, PO4, and Mag2+ are within normal values
- once lytes corrected, incr to 40mL/h
50
Nursing assessments before starting enteral feed
- resp: RR, breath sounds
- CNS: LOC, gag reflex
- GI: q4h + prn or prior to each bolus feed -- appetite, N/V/D, pain/discomfort, abd distension, bowel sounds, LBM, diarrhea/constipation, farts
- Hydration: mouth, skin turgor, urine
- weight, if needed, 2x/week
- feeding tube site: nasal/abdomen -- red, warmth, bleeding/irritation, drainage, dressing
- feeding solution, expiry date, rate of admin
- **external length measurement of tube** (nasal)
51
how often do we monitor tube position during continuous enteral feeding & before each use?
Q4H
- if external length of tube changed/ malposition suspected, STOP tube for feeding, flushing, or meds, and notify MRP asap
52
Monitoring enteral feed
- HOB 30-45 degrees of higher during all feeds (don't lower for nocturnal feeds)
- HOB elevated one hour after bolus feeding
- aspiration risk
- discomfort, tolerance (n, bloating, abdo pain)
53
# Enteral feed
What to assess for tolerance/intolerance?
intolerance:
- bloating, BS, N/V, feeling of fullness, distention, stools, urine output
- dumping syndrome – incr fluid in intestines, diarrhea
refeeding syndrome - monitor bldwork, clinical indicators
Gastric tubes: check residuels
monitor weight (monday & thurs)
54
When do you flush a feeding tube?
- flush q4h with 50ml for continuous feeds
- before & between meds w/ at least 15 mL + flush 30 mL after all meds
- pre and post bolus feeds
- flush 50 mL BID if feeding tube not in use
55
what water to use for feeding tube flushes?
- tap h2o for routine flushes unless otherwise ordered --> clean, safe drinking h2o from uncontaminated source
- flush with sterile h2o for immunocompromised pts (& infants less than 1 year)
56
PEG/ PEJ site care
1. cleanse site + under crossbar/disc daily w/ mild soap & h2o, pat dry
can return to routine showering/bathing in ~1 week
2. daily rotation of skin disc/cross bar to prevent skin breakdown
3. daily rotation of gastrostomy tube (90-360 degrees) to release sticking + promote tract formation
4. dressing, if needed. not necessary after site healed unless drainage. can apply barrier cream prn
5. C&S swab if S&S infection
56
why don't we rotate J-tubes?
it can become twisted and blocked
57
Nursing care after bolus enteral feed
- pt sitting upright for 1h post feed
- GI reassessment
- evaluate effects/tolerance (e.g., severe diarrhea > 3-4x/24h = notify MRP/dietician)
- mouth care q4h + prn
- nasal site care prn
58
# Enteral feeds
Holding/Stopping Feeds - what can happen
can lead to pts receiving insufficient calories/proteins
59
Holding/Stopping Enteral Feeds - what to do
1. don't stop tube feeds during routine care, pt positioning when HOB lowered, or durign bedside procedures unless specifically ordered
return HOB > 30 degrees asap
2. if feeding interrupted, e.g., test, surgery, resume feeding @ same rate unless ordered change
3. don't stop feeds or decr rate for single elevated GRV, absent BS, diarrhea, or emesis related to suctioning
60
What is a gastric residual? what is its indication?
= volume of fluid remaining in stomach before/during gastric feed. incr residuals may indicate delayed gastric emptying
indication = determine delayed gastric emptying if unable to asses for s/s intolerance in pt
in gastric tubes only - PEG + large bore NG, not small bore (more resistance during aspirations, more likely to collapse w/ negative pressure)
60
when would you consider holding an enteral feed?
prior to supine physiotherapy, e.g., gastric feeding, unprotected airway
61
Feeding Tube Med Admin Important Points
1. flush w/ tap h2o pre & post med admin to prevent clogging
2. ensure med can be crushed, if not, contact pharmacy
3. some capsules can be opened and mixed w/ h2o
4. if crushing, crush into fine powder + dissolve in min. 30mL h2o (don't mix diff tgt)
5. ensure med is compatible w/ tube feed solution
6. add 5-10mL tap h2o to thick meds to prevent blockage
7. @ bedside, add h20 just prior admin so med doesn't clump
62
IH Med Admin Flushing
pre: flush 15-30mL h2o
admin each med separately, mixed w/ 30mL h2o as indicated
flush 15mL in b/t each med
flush 30mL after final med
63
Reasons for tube occlusion
- inadequate flushing
- tube resting on mucosa wall (reposition pt)
- coagulation of enteral feed formula
- too small bore feeding tube
- certain meds (syrups), combining meds, not crushing fine enough
64
how to prevent tube occlusion
flush w min 30 mL h2o q4h when feeds are stopped for any reason
65
how do you declog a feeding tube?
- pancrelipase plain 1 tablet or capsule prn
- sodium bicarbonate 500 mg tablet prn
notify physician / follow PPO procedure for flushing + declogging
66
skin problems associated w/ PEG/PEJ + G/J tube sites
- skin irritation from tube/allergy to product
- mechanical trauma (tube moving too much in stoma)
- chemical dermatitis (from leaking stomach contents)
- infection – folliculitis, candidiasis, cellulitis
- granulation tissue formation
