Test 2 Enteral Nutrition Flashcards
Contraindications for EN
- Mechanical obstruction
- Necrotizing enterocolitis
- Severe diarrhea/vomiting
- Enteric fistulas
- Severe GI hemorrhage
- Intestinal dysmotility
- Short bowel syndrome
Nasogastric (NG)
from nose to stomach
Orogastric (OG)
from mouth to stomach
Nasoduodenal
ND
- from nose to duodenum
- aka “transpyloric”
Nasojejunal (NJ)
- from nose to jejunum
- “transpyloric”
Gastrostomy (G-tube)
straight into the stomach
Jejunostomy (J-tube)
directly into jejunum
indications for NG or OG
- Intact gag reflex
- Normal gastric emptying
- for short term 4-6 weeks
advantages for NG or OG
- Ease of placement
- Inexpensive
disadvantages for NG or OG
- Potential tube displacement
- Potential ↑ aspiration risk
indications for ND or NJ
- Impaired gastric motility or emptying
- High risk of reflux or aspiration
- for short term 4-6 weeks
advantages for ND or NJ
- Reduced aspiration risk
- Early feeding
disadvantages for ND or NJ
- Skill needed for placement - Potential tube displacement or clogging
- Bolus or intermittent feeding not tolerated
indications for G-tube
- Normal gastric emptying
- long term use
advantages for G-tube
- Tubes less likely to clog
- Low profile buttons available
disadvantages for G-tube
- Surgical placement
- Potential aspiration risk
- Requires stoma site care
indications for J-tube
- Impaired gastric motility or emptying
- High risk of reflux or aspiration
- long term use
advantages of J-tube
- Early feeding
- Potential ↓ aspiration risk
disadvantages of J-tube
- Surgical placement
- Bolus or intermittent feeding not tolerated
- Requires stoma site care
EN methods of admin: bolus
- Commonly used in long-term care settings in patients with G-tube
- Delivered over 5-10 minutes
- Administered via syringe
- Not recommended in patients with delayed gastric emptying, with duodenal/jenunal tubes, and/or at high risk of aspiration.
EN methods of admin: intermittent
- Delivered over 20-60 minutes
- Used in G-tube, NG/OG tube
- Administered by enteral pump
- Not recommended in patients with duodenal/jejunal tubes
EN methods of admin: continuous
- used in transpyloric tube
- Delivered over 24 hours (mL/hour)
- Administered by enteral pump
EN methods of admin: cyclic
- Used in patients not eating well because of lack of appetite
- Administered by enteral pump over nighttime hours (e.g., 12 hours)
- Patient must be relatively stable to tolerate
- used G-tube and J-tube
Carbohydrates
- major source of calories
- polymeric or intact
- hydrolyzed
- caloric contribution: 4kcal/gram
Protein
- polymeric or intact
- partially hydrolyzed
- caloric contribution: 4kcal/gram
Fat
- polymeric or intact
- partially hydrolyzed
- concentrated source of kcal = 9kcal/gram
Standard EN formula
- polymeric
- balanced mix of carb, fat, protein
- isotonic ~ 300mOsm/L
- 1-1.2kcal/mL
- tube admin only
Modified EN formula: high protein
- for critically-ill adults
- adults that require > 1.5g/kg/day
Modified EN formula: high calorie
- concentrated to decrease fluid intake
- provides 2kcal/mL
Hydrolyzed EN formula
- “pre-digested”
- hydrolyzed protein and/or fat
- for pts who are intolerant to standard formula
- higher osmotic load which can lead to diarrhea
Disease-specific formulations
- Renal – calorie dense, low electrolyte content
- Hepatic – increased branched chain and decreased aromatic amino acids
- Pulmonary – High fat, low carbohydrate
- Diabetic – High fat, low carbohydrate
- Immune-modulating – supplemented with glutamine, arginine, nucleotides, and/or omega-3 fatty acids
Oral supplements
- Used to enhance oral diet - Sweetened, meant to be taken by mouth
- Hypertonic (450-700 mOsm/kg)
Complications: Diarrhea
- Causes: malabsorption, tube-feeding related, drug related
- Management: decrease rate of feeding, try different formula, check osmolality and sorbitol content of liquid medications
Complications: Nausea/vomiting
- Causes: Gastric dysmotility, rapid infusion of hyperosmolar formula
- Management: Decrease rate of feedings
Complications: Constipation
- Causes: Tube-feeding related, drug related, patient specific
- Management: change to high fiber formula, increase fluid intake, review pt profile for meds associated with constip.
Complications: Abdominal distention
- Causes: Too rapid formula administration, too large volume per feeding
- Management: decrease rate of continuous feedings, decrease volume of intermittent feedings
Complications: Occluded feeding tube
- Insoluble complex of enteral formula and medication, inadequate flushing of feeding tube, kinking of tube
- Management: Flush tube before and after medication administration, Avoid use of syrups and medications with thick consistency
Complications: Tube displacement
- Inadvertent removal, vomiting or coughing, inadequate fixation
Complications: Aspiration
- Improper patient position, gastroparesis, feeding tube not positioned properly, compromised lower esophageal sphincter, diminished gag reflex
- Management: Maintain appropriate positioning, Consider change to transpyloric feedings
Complications: Peri-stomal excoriation
- Improper skin and tube care, GI secretions leaking onto area
- Management: Apply topical barrier creams
Complications: Increased infection risk
Aspiration of gastric contents, sinusitis (NG tube), cellulitis (G-tube)
issues with syrups in tubes
- syrup has pH of about 4
- acidic solutions bind to the feeding and clump it up
Which medications can clog the tube?
- Phenytoin
- Fluoroquinolones
- Tetracyclines
- Omeprazole, lansoprazole
- Warfarin
Phenytoin
- bind to Ca or protein feeds
- solution: hold feed 1-2 hrs before and after phenytoin; monitor phen. concentration and clinical response, increase dose
Fluoroquinolones
- binds with divalent and trivalent cations in feeds
- solution: hold feed 1 hr before and after fluor., avoid j-tube administration of cipro
Tetracyclines
- binds with divalent and trivalent cations in feeds
- solution: hold feed 1 hour before and after tetracycline
Omeprazole, lansoprazole
- Granules become sticky and clog tube
- solution: prepare extemporaneous preparation
Warfarin
- binds with proteins in enteral feeds
- solution: monitor INR, increase dose, hold feed 1 hr before and after warfarin
