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104-theme 1- the alimentary system > nutrition support > Flashcards

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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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13
Q

what do PEG and RIG stand for?

A
  • Percutaneous endoscopic gastrostomy (PEG) or radiology inserted gastrostomy (RIG)
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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
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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?
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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
Q

what is the pathogenesis of refeeding syndromes? 7

A
  • 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
Q

how do we avoid/ treat refeeding syndrome? 5

A
  • 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
Q

what is Wernicke- Korsakoff’s syndrome? 7

A
  • 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
Q

how do we treat Wernicke- Korsakoff’s syndrome? 5

A
  • 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
Q

what is the best supportive care for malnourished people? 3

A
  • Oral nutrition supplements
  • Oral hydration
  • Antiemetics
30
Q

what is the significance of feeding? 4

A
  • 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
Q

describe a doctors duty of care and providing nutrition? 3

A
  • 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
Q

how could PEG be a benefit?

A
  • 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

104-theme 1- the alimentary system (17 decks)

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