Enteral nutrition

Question 1

Malnutrition definition

Answer 1

Not meeting the metabolic demands of the body/nutrition imbalance
typically associated with weight loss (undernutrition)
but also applies to obesity (overnutrition)

Question 2

populations susceptible to malnutrition

Answer 2

Age: elderly, infants
GI conditions (IBD, bariatric surgery, pancreatitis)
Cancer
AIDS
Developmental disabilities (CP, swallow reflex)
Hospitalized patients

Question 3

How long before most patients require nutritional support (inpatient, hospitalized)

Answer 3

Most go 7 days before starting nutrition support

Question 4

Critically ill / ICU patients can start enteral nutrition _____

Answer 4

earlier than the 7 days due to mortality benefit

Question 5

When do outpatients require nutritional support?

Answer 5

patients with malnutrition or at risk of developing malnutrition
If the gut works – use it

Question 6

When to use enteral vs parenteral

Answer 6

If the gut is functioning, use it. TPN has lots of AE
Must use gut to maintain integrity

Question 7

Why do we want to maintain gut integrity?

Answer 7

Keeps bile flowing (bacteriostatic flow) = prevent infection
Prevents stones (cholestasis/cholelithiasis)
Immune defense: GALT, stomach acid, protective mucosal layer, peristalsis, healthy microbiota

Question 8

Enteral nutrition tubes (3)

Answer 8

Nasal tubes (NG, ND, NJ)
Abdominal wall placement (G, J)

Question 9

Nasogastric tubes

Answer 9

easy to place
highest aspiration risk into lung
Can push large volume
Stomach decompression possible (if intestinal block, can such material out of stomach)

Question 10

Naso -jejunal/-duodenal tubes

Answer 10

more difficult to place
reduced aspiration risk
More likely to clog (smaller tube)
Can’t push large volume

Question 11

Abdominal wall G tube

Answer 11

Can give larger volume bolus feeds that mimic meals (push 15min-1hr)

OK to crush and flush meds

Question 12

Abdominal wall J tube

Answer 12

Can’t give large volumes
Must give medications as a liquid
Can’t crush/flush meds

Question 13

Abdominal wall J tube

Answer 13

Can’t give large volumes
Must give medications as a liquid
Can’t crush/flush meds

Question 14

Crushing/Flushing medications

Answer 14

Flush with 15-30 mL sterile water before and after
NOT FOR JEJUNAL TUBES (gastric and duodenal OK)
Do each medication separately
Do not crush SR, ER, or enteric coated

Question 15

Giving liquid medications

Answer 15

Check osmolality
>600 mOsm = dilute with sterile water or else may cause diarrhea

If viscous - dilute or it could stick to the tubing

Question 16

Enteral feeding interactions

Answer 16

Must stop enteral feed to give med

Question 17

Medications that require feed hold 1-2 hrs before/after

Answer 17

Phenytoin
Fluoroquinolones abx
Levothyroxine (give IV if need adjust dose)
Warfarin (PO only)

Question 18

Calculate caloric requirement for enteral nutrition

Answer 18

20-30 kcal/kg/day

Question 19

Do patients usually require specialized enteral preps?

Answer 19

No, generally use standard prep

Question 20

Which patients require specialized EN?

Answer 20

Renal/heart failure (fluid restrict)
End stage renal disease
Diabetes
Burn/trauma
Pancreatitis

Question 21

Renal/HF EN adjustment

Answer 21

Less volume – use more concentrated formula

Question 22

ESRD EN adjustment

Answer 22

Reduce potassium and phosphate

Question 23

Diabetes EN adjustment

Answer 23

Calories – more fat and fiber, less sugar

Question 24

Burn/trauma EN adjustment

Answer 24

High protein

Question 25

Pancreatitis EN adjustment

Answer 25

low fat

Question 26

Administering EN

Answer 26

Bolus feed (G tube)
Continuous feed (inpatient only)
Semicontinuous (overnight)

Question 27

Bolus feeds calc mL

Answer 27

only for Gastric tubes/NG tubes
Bolus - 200mL at a time given over 15-60 min
# boluses = total volume /200mL

Question 28

If you give a 200 mL NG bolus and the patient vomits, what do you do next?

Answer 28

Decrease volume
or
infuse over longer period of time

Question 29

Continuous feeds rate

Answer 29

The goal rate = total mL/24 hrs
Intiate as 20ml/hr
Increase based on tolerance
Reassess every 4 hours until at goal

Question 30

Calculate EN fluid requirements

Answer 30

1 mL/kcal/day

or

30-40 ml/kg/day

Question 31

Calculate how much water to give on top of EN

Answer 31

Daily fluid requirement – Enteral H2O content
– daily fluid adult - 30-40ml/kg/d

Give this divided Q 4-6 hours as free water
ex: every 4 hrs (divide by 6)

Question 32

Monitoring EN intolerance

Answer 32

Diarrhea
Bloating/distention
Electrolytes
GI wall
Nasal tube
Clogs

Question 33

Diarrhea monitoring EN

Answer 33

> 3 liquid stools
influenced by
- feed rate (fast=D)
- osmolality (too high = D)
- lack of fiber (also helps absorb water)
- prokinetics (can cause diarrhea)

Question 34

Bloating/distention monitoring EN

Answer 34

Use prokinetics to help
Give post pyloric (avoid gastric - ferment)
Use continuous EN – slow infusion rate
If bolus – decrease mL of bolus

Question 35

Electrolyte EN monitoring

Answer 35

Check for hypernatremia (pt unable to sense thrist or unable to communicate)
Refeeding syndrome (rapid shift)

Question 36

GI wall tube monitoring

Answer 36

Check exit site infections
Leaking
Bleeding

Question 37

Nasal tube monitoring

Answer 37

Sinusitis
keep elevated to reduce risk of aspiration (30-45 deg)

Question 38

Tube monitoring

Answer 38

Maintain patency
Flush with water before/after
Pancreatic enzymes + bicarb to clear