4900:C5 Enteral & Parenteral Nutrition Support Flashcards
(98 cards)
1
Q
bolus feedings
A
rapid administration of 250-500mL of formula several times daily.
2
Q
colonocyte
A
epithelial cell of the large intestine or colon
3
Q
enteral nutriton (EN)
A
feeding through the gastrointestinal tract using a tube, catheter, of stoma that delivers nutrients distal to the oral cavity.
4
Q
gastrostomey
A
an opening into the stomach
5
Q
implantable port
A
intravenous access device that is completely under the skin, is placed in the vein on the upper chest wall, and exits the body near the typhoid process, axilla, or abdominal wall
6
Q
intermittent feedings
A
administration of formula several times daily, over 20-30 minutes
7
Q
nasointestinal feeding tube
A
a tube that is inserted nasally past the stomach into the intestine.
8
Q
orogastric feeding tube
A
a tube that is inserted orally into the stomach
9
Q
osmolality
A
number of water attracting particles per wt of water in kg
10
Q
osmolarity
A
number of millimoles of liquid or solid in a liter of solution.
11
Q
parenteral nutriton (PN)
A
administration of nutrition directly into the circulatory system
12
Q
percutaneous endscopic gastrostomey (PEG)
A
a procedure used by a physician to insert a feeding tube through the skin and into the stomach using an endoscope.
13
Q
peripherally inserted central catheter (PICC)
A
intravenous access device inserted into the arm and threaded into the subclavian vein to the vena cava.
14
Q
propofol
A
lipid based drug that is used to maintain sedation during mechanical ventilation. Also, must be considered as a source of energy.
15
Q
refeeding syndrome
A
metabolic alterations that may occur during nutritional repletion of starved patients. Electrolytes involved: Phosphorous, Mg, K and thiamin, need for all increases with return to metabolism of glucose.
16
Q
ostomy
A
an artificial opening created by surgical procedure.
17
Q
stylet
A
wire guide within the enteral tube that assists with insertion.
18
Q
tunneled catheter
A
intravenous access device that is placed in the vein on the upper chest wall and exits the body near the typhoid process, axilla, or abdominal wall.
19
Q
nasogastric feeding tube
A
A tube that is inserted nasally into the stomach. Uses when GI function is normal.
20
Q
Advantages of a nasogastric tube
A
Uses & stimulates normal digestive function; flexibility in administration; medication can be placed in this tube; tube insertion at bedside.
21
Q
Disadvantages of nasogastric tube
A
Aspiration; discomfort for pt; nasal irritation; tube displacement
22
Q
Nasoduodenal feeding tube used when?
A
Normal sm intestine function; need to bypass stomach as primary site of feeding
23
Q
Advantages & disadvantages of nasoduodean tube
A
A: tube insertion at bedside. D: discomfort for pt; tube displacement
24
Q
Nasojejunal tube Indications?
A
Norma sm intestine function; need to bypass stomach as primary site of feeding.
25
Advantages & disadvantages of Nasojejunal tube
A: tube insertion at bedside. D: discomfort for pt; tube displacement
26
Gastrostomy indications
Normal GI function but need to bypass upper GL tract; long-term feeding access.
27
Advantages of gastrostomy
Longer-term feeding access; reduced risk of tube displacement; allows for bolus feeding
28
Disadvantages of gastrostomy
surgical procedure; risk if irritation and infection for insertion site.
29
PEG (percutaneous endoscopic gastrostomy) indications
Normal GI function but need to bypass upper GI tract; longer-term feeding access.
30
Advantages of PEG
Outpatient procedure without risk of anesthesia; longer-term feeding access; less expensive than surgical insertion; reduced risk of tube displacement; allows for bolus feedings
31
Disadvantages of PEG
risk of irritation and infection for insertion site.
32
Jejunostomy indications
Normal GI function but need to bypass components of GI tract; longer-term feeding access
33
Advantages of Jejunostomy
Increased tolerance for early initiation of enteral feeding
34
Disadvantages of jejunostomy
surgical procedure; risk of irritation & infection for insertion site; with smaller lumen of tube, the risk of clogging may be greater
35
Protein content of enteral formulas
10-15%. Up to 25% for high PRO needs
36
medical foods
Foods administered under the supervision of a physician & intended for the specific dietary management of a disease for which distinctive nutritional requirements are established.
37
Feeding tubes outer diameter is measured in?
French size. 1 Fr = .33 mm. Most are 10-14Fr
38
Step : Enteral Nutrition Rx
Determine a "dosing" wt. What is the pt's ideal body wt?
39
Step 2 & 3: Enteral Nutrition Rx
2. Determine a kcal goal. 25-30kcal/kg, &/or use Mifflin-St. Jeor 3. Adjust for activity and injury as needed.
40
Step 4: Enteral Nutrition Rx
Calculate a protein goal. Multiply by 0.8 = g needed/ day. Multiply g needed by 4 to determine kcal needed/ day from protein.
41
Step 5 & 6: Enteral Nutrition Rx
5. Consider electrolytes needed 6. consider Vit & minerals needed. Consult DRI tables and any abnormal losses.
42
Step 7: Enteral Nutrition Rx
Determine fluid needs. Bases on body wt or 1mL/kcal. Consider hydration status of pt.
43
Step 8 Enteral Nutrition Rx
Establish administration & delivery method
44
Step 9: Enteral Nutrition Rx
Write final enteral nutrition prescription: determine formula to use and at what rate it should be given. First determine how many mL will meet pt's kcal needs. Second, verify that this meets PRO needs. Third, determine at what rate is should be administered.
45
A standard isotonic polymeric formula can be initiated at full strength at what rate
10-50mL/hr, and then increases to goal rate.
46
Common complications associated with tube-feeding
Tube-related complications. GI complications. Aspiration. Dehydration. Electrolyte imbalances. Under/Overfeeding. Hyperglycemia. Re-feeding syndrome
47
Current ASPEN guidelines for obese tube fed pt?
For all classes of obesity, the goal of the EN regimen should not exceed 60-70% of target energy requirements, or 11-14kcal/kg actual body wt /day (or 22-24kcal/kg IBW /day)
48
Result of drop in phosphorous related to refeeding syndrome
hemolysis, impaired cardiac function, impaired respiratory function and even death.
49
two-in-one PN solution
solutions that contain dextrose and AAs. Lipids must be given separately. Has the benefit of being clear so precipitate can been seen.
50
three-in-one PN solution
solutions that contain dextrose, AAs, and lipids.
51
In what form is PRO included in PN formulas
Included in parenteral nutrition in the form of individual AA.
52
CHO source for PN?
dextrose monohydrate. 3.4kcal/g.
53
Minimum amount of CHO needed to spare lean body mass?
100g CHO is needed /day for protein sparing. DRI = 130g/day. 1mg/kg/min
54
Source of lipid in PN solutions?
soybean or safflower oil.
55
Lipid emulsion in PN provides
Essential fatty acids, Vit K, as well as concentrated source of energy
56
Step 1 & 2: Parenteral Nutrition Rx
1. determine the dosing wt. 2. determine a kcal goal. (25kcal x wt (kg)) or Mifflin-St. Jeor
57
Step 3: parenteral Nutrition Rx
Adjust kcal goal for activity and injury
58
Step 4: Parenteral Nutrition Rx
Calculate a protein goal. 0.8g/kg - 1.5g/kg
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Step 5: Parenteral Nutrition Rx
Determine fluid requirements (provides a working V for the parenteral solution). 1mL/kg
60
Step 6: Parenteral Nutrition Rx
Determine lipid concentration. Minimum lipid emulsion concentration is apx 3%, and the max that should be administered to the pt is 1.2g/kg.
61
Step 7: Parenteral Nutrition Rx
Determine protein concentration. Divide PROg needs by total daily VmL and multiply by 100 = % AA solution
62
Step 8: parenteral nutriton Rx
Determine g of dextrose to meet remaining energy requirements. Subtract kcal from PRO & lipid to determine remaining kcal need. Divide remaining kcal by 3.4kcal/g = g dextrose needed, then divide by total daily V x 100 to find % of dextrose for solution.
63
Step 9: parenteral nutriton Rx
Consider electrolyte needs
64
Step 10: parenteral nutrition Rx
Consider vitamin & mineral needs. Be sure to check package insert to be sure of what the pt is getting.
65
Step 11: parenteral nutrition Rx
Write the final parenteral nutrition prescription. Includes g of PRO, lipid, dextrose; lists amounts of all Vit & minerals; lists total daily V, and how many mL/hr/day. Also goal rate /day.
66
When is enteral nutrition indicated?
Impaired nutrient ingestion ex. stroke. Inability to consume adequate nutrition orally, ex. cancer, anorexia. Impaired digestion, absorption, metabolism, ex. Crohn's. Severe wasting, impaired growth, ex. AIDS
67
When is enteral nutrition indicated in children?
Unable to obtain >80% of caloric needs by mouth, or if require extended time period to eat >4 hours/day. Malnutrition of poor growth. Decrease of 2 or more wt or ht growth channels or persistent TSF <5%tile.
68
How long before an adult should be put on enteral feeding?
7-14days with inadeequate oral intake, or if inadequate intake is expected over 7-14 days.
69
What are clinical condition criteria for enteral feeding of a pt.
Pt must have bowel sounds - digestive & absorptive capabilities, be hemodynamically stable. Non-tender & soft abdomen
70
Advantages of enteral feeding
Physiologic - the gut & liver metabolize and utilize nutrients more effectively via enteral vs parenteral route. Immunologic. Biochemical/metabolic. Safety. Cost. Early feeding modulating the stress response.
71
Immunological role of ENS
GI tract is a major immunologic organ. Gut is a major source of immunoglobulins. Gut produces >70% of the body's IgG. GALT is key component to mucosal barrier.
72
Why is maintenance of the GI mucosa crucial?
Crucial to preventing atrophy & bacterial translocation.
73
Bacterial translocation
ability of bacteria & endotoxins from the gut to migrate from the GI tract into the systemic circulation.
74
What is prevention of bacterial translocation imperative in the critically ill pt?
BT is hypothesized to be a major etiologic factor contributing to infections & organ failure in critically ill patients.
75
What is the most important stimulus for mucosal cell proliferation?
The presence of nutrients in the gut is the most important stimulus for mucosal cell proliferation.
76
What are the main causes of gut mucosal cell atrophy?
malnutrition, prolonged NPO, TPN.
77
What is the result of gut mucosal cell atrophy
Decreased enzyme & Ig production
78
What are the gut' primary fuels?
Glutamine and SCFA's
79
Glutamine
A non-essential amino acid that is the primary fuel for enterocytes.
80
SCFA's
Are produced in small amounts when dietary fiber is fermented in the colon, absorbed through the portal vein during lipid digestion: butyrate, propionate, acetate. Are the primary fuel for colonocytes.
81
What factors are used to decide selection of enteral access?
Disease state. Aspiration risk. GI anatomy. Gastric & intestinal motility and function. Estimated length of therapy
82
Nasoenteric
Nasogastric, nasoduodenal, nasojejeunal. Inserted at bedside.
83
Advantages of nasoenteric tubes
Relatively easy to insert. Lrg. reservoir capacity in stomach. V, osmolality usually not a problem.
84
Disadvantages of nasoenteric tubes
Increased risk of aspiration. Easily dislodged. Intended for short-term use <30 days.
85
Orogastric tube is indicated when?
Pediatrics - does not obstruct nasal passage. <34 weeks gestation w/ gag reflex. Basilar skull fx. Nasal prong CPAP. Respiratory distress. Requires oxygen. Nasal trauma.
86
Nasoduodenal advantages vs disadvantages?
Gastric emptying not a problem. Decreased risk of aspiration. Small intestine more sensitive to V and osmolality - >300mOml. Pump required for administration to control flow rate.
87
What types of tubes are placed endoscopicly?
Gastrostomey (G-tube). Percutaneous endoscopic gastrostomy (PEG). Jejunostomy (PEJ). Utilized for long term provision ofenteral nutrition support (>30 days).
88
Gastrostomy (G-tube)
Long term provision of enteral nutrition. Surgical procedure. Normal gastric function & anatomy required.
89
PEG tube
percutaneously inserted after endoscopic guidance. Local anesthesia. Fewer complications & less costly than surgical gastrostomy. Ease of closure after removal of tube. Clog easily. Difficult in obese.
90
Jejunostomy
Long term ENS anticipated. Increased potential for complications - tube occlusion due to smaller lumen size, GI intolerance.
91
Types of jejunostomy:
needle catheter jejunostomy, PEJ
92
Where do we find information about the ability to tolerate enteral feedings?
MD hx & physical. Current hospital course - surgical record, daily progress notes. RN abdominal assessment - bowel sounds. Intake/output - is bowel movement present?
93
What to look for in inspection of the abdomen?
Skin changes. Symmetry. Contour - flat, rounded, etc. Observable masses. Movement - pulsations & peristalsis.
94
Auscultation of abdomen
Normal bowel sounds occur 5-35 x per minute - sounds like high pitched gurgles. "standard practice" - cannot describe absent bowel sounds unless none noted for 5 minutes in each quadrant.
95
Percussion of abdomen
Used to determine presence of fluid, distention, & masses. Higher pitched hollow sound - tympany - "normal". presence of fluid or masses causes short high pitched sound with little resonance - "dullness"
96
Is the practice of auscultation evidenced based?
No, but it is still a part of current abdominal assessment. Conflicting information on how to listen, as well as the significance of normal vs abnormal sounds
97
When do we start feeding?
In pediatrics - immediately when hemodynamically stable. Adults: when feeding is expected to to last more than 5-7 days for malnourished, or 7-9 days for adequately nourished. 24-48 hours in critically ill.
98
How long after PEG placement can feeding begin?
two hours.
