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Nutrition > Enteral & Parenteral Nutrition > Flashcards

Enteral & Parenteral Nutrition Flashcards

1
Q

Which patient has a higher risk for malnourishment - a mobile patient or one on bedrest?

A
  • patient on bedrest
  • often more ill
  • decreased appetite because less energy expenditure
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2
Q

What type of diet should a patient with renal failure adopt?

A

Low protein; easier on kidneys

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3
Q

What is malnutrition?

A
  • Includes both the deficiency or excess or imbalance of energy, protein and other nutrients
    1) Under-nutrition resulting from insufficient food intake
    2) Over-nutrition caused by excessive food intake
    3) Specific nutrient deficiencies
    4) Imbalance due to disproportionate food intake
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4
Q

Those who are malnourished are 2x more likely to…

A

Develop a pressure ulcer

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5
Q

What percentage of malnutrition is disease-related?

A

76%

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6
Q

T or F: malnourished patients are more likely to die in hospital

A

True; 7.4x more likely

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7
Q

T or F: malnourished patients are more likely to be readmitted

A

True; 1.6x higher odds

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8
Q

Malnutrition is associated with an increased risk of….

A
  • morbidity in acute and chronic diseases
  • infections
  • post-op complications
  • mortality
  • pressure wound ulcers
  • poor wound healing
  • delayed functional improvement
  • increased length of stay
  • increased readmission rates
  • delay in the initiation of adjunctive treatment
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9
Q

What is one of the best indicators of malnutrition risk?

A

Involuntary weight loss of 10% of usual body weight preceding 6 months of hospital admission

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10
Q

What 4 basic questions can nurses ask upon admission for the early identification of nutritional risk?

A

In order of importance:

  1. Have you lost weight in the past 6 months?
  2. If yes, how much weight have you lost and over what time frame?
  3. What is your current weight?
  4. What is your height?

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11
Q

What 2 questions does the Canadian Nutrition Screening Tool?

A
  1. Have you lost weight in the past 6 months without trying?

2. Have you been eating less than usual for more than a week?

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12
Q

What is the cause of malnutrition in the hospital?

A
  • in developed countries, the cause is disease not starvation
  • pro-inflammatory effect of illness is the culprit
  • any disease has the potential to cause malnutrition: response to trauma, infection or inflammation may alter metabolism, appetite, absorption or assimilation of nutrients
  • poor intake in hospital also due to organizational or patient factors
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13
Q

What are 8 organizational factors that result in poor intake?

A
  • lack of nutrition awareness by HCPs and patients
  • inappropriate NPO status
  • multiple medical tests requiring fasted states
  • unprotected meal times (diagnostics, visitors, transfers) – staff may forget to give food to patient when meal is missed
  • adverse hospital smells and noises
  • lack of assistance at meals
  • food services issues (unpalatable food, cold food, selective options)
  • lack of nutritious food options outside of meal times
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14
Q

What are patient factors that result in poor intake?

A
  • illness effects (poor appetite, too sick, tired, or in pain)
  • eating difficulties (cannot open or unwrap food, uncomfortable position, difficulty reaching food, difficulty chewing and swallowing)
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15
Q

Who is responsible for the nutritional health of hospitalized patients?

A

All health care employees

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16
Q

What are the 3 categories of clinical nutrition interventions?

A

1) Oral route
2) Enteral nutrition (tube feeding)
3) Parenteral nutrition (IV or total parenteral nutrition)

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17
Q

What are 3 interventions for the oral nutrition?

A
  • optimize oral intake (snacks and preferences)
  • food fortification (costly, unpalatable)
  • oral nutrition supplementation (effective and cost friendly)

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18
Q

What are the indications for oral nutrition intervention?

A
  • consistent with medical and patient’s goals 

  • inadequate oral intake to meet nutrient needs

  • functional gastrointestinal tract
  • safe functional swallow
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19
Q

What is automatic nutrition supplementation?

A
  • all patients admitted to medical floor > 65 yo receive Ensure meal trays
  • cost benefit and reduces length of stay and readmission rate
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20
Q

What is the benefit of adding nutrition supplementation to malnourished patients?

A
  • increased QoL, reduced infections, decreased length os stay, fewer pressure ulcers
  • patients identified at risk by screening tool in ER, received Ensure plus or Glucerna on meal trays automatically
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21
Q

Can nurses make a difference?

A
  • consumption of 50-65% of meals and supplements can halt or minimize the catastrophic effects of hospital malnutrition
  • can encourage, emphasize, and reinforce the importance of nutrition
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22
Q

How can nurses promote oral supplement compliance?

A
  • encourage sampling of different flavours
  • serve cold or with ice
  • if nausea too strong or odours are an issue, serve with a lid and straw
  • keep within patient’s reach
  • encourage sips
  • watch your facial expression
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23
Q

What is enteral nutrition?

A

Delivery of nutrients to the gastrointestinal tract via a tube

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24
Q

What are the indications for enteral nutrition?

A
  • consistent with medical and patient goals
  • oral intake is deemed unsafe, inadequate, or impossible to meet nutrient needs
  • functional gastrointestinal tract
  • accessible gastrointestinal tract
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25
Q

What are the benefits of EN vs TPN?

A
  • safer than TPN
    less expensive than TPN
  • preserves GI tract integrity and function
  • reduce infectious and non-infectious complications associated with disease and injury
  • patient may still be able to eat orally
26
Q

What conditions may necessitate EN?

A

1) Impaired ingestion (intubation, facial or esophageal trauma, stroke)
2) Inability to consume adequate nutrition due to:
condition (hyperemesis of pregnancy, anorexia associated with CHF) or
a hyper-catabolic state (Bone Marrow Transplant, severe burns, sepsis)

3) Impaired digestion and absorption (pancreatic cancer, short bowel, pancreatitis, gastroparesis
)
4) Severe wasting/malnutrition
(End Stage Liver Disease awaiting transplant, severe Crohn’s disease)

27
Q

What are contraindications for EN?

A
  • non-operative mechanical GI obstruction
  • intractable vomiting/diarrhea
  • paralytic ileus
  • severe GI bleed
  • perforation of the GI tract
  • inability to gain access to the GI tract
  • aggressive intervention not warranted or not desired
28
Q

What are the 2 enteral feeding routes?

A

1) Nasoenteric (nasogastric, nasoduodenal, nasojejunal)
- short-term (<3-4 weeks)

2) Percutaneous enterostomy (gastrostomy [PEG] or jejunostomy)
- long-term (>4 weeks)

29
Q

How are EN routes chose?

A

Based on access and expected duration (NG short-term, PEG long-term)

30
Q

Tube feeding supplies should be changed…

A

24 hours

31
Q

What are polymeric formulas for EN?

A
  • require digestive capability
  • standard formula: CVA with swallowing dysfunction
  • higher protein: post-surgery, pressure ulcer, burns, wounds, sepsis
  • nutrient dense: hyper-catabolism, fluid restriction
32
Q

What are semi-elemental formulas for EN?

A
  • require minimal digestion for absorption
  • easily digested and assimilated
  • for gastrointestinal impairment such as gastroparesis
  • or malabsorptive conditions such as pancreatitis or chemotherapy
  • also depends on route; if going directly into intestines than protein should already be broken down
33
Q

What are important steps to follow when administering EN?

A
  • use aseptic technique
  • label EN equipment
  • elevate HOB 30 degrees
  • ensure right patient, right formula, right tube
34
Q

What are enteral misconnections?

A
  • inadvertent connections between enteral feeding systems and
    non-enteral systems such as intravascular lines, peritoneal dialysis
    catheters, tracheostomy tube cuffs, and medical gas tubing
  • of low frequency but high consequence
  • not one-size-fits-all
  • international initiative to standardize enteral feeding tubes and connectors
35
Q

Should EN be discontinued if the patient has diarrhea?

A

Not right away; do more investigation first

36
Q

What are considerations for medication delivery via EN?

A
  • preferred route is oral
  • some require stomach acid to be activated
  • medications can interact with the formula, 
don’t mix together
  • many cannot be crushed (slow release or 
enteric coated)
  • pharmacy has a list of meds and how to properly administer
  • formula may need to be held for 1-2 hrs before and after a med (phenytoin, ciprofloxacin)
  • flush, med, flush – give meds individually, do not mix or add to feeding container
37
Q

What are potential complications of EN?

A
  • aspiration
  • nausea
  • vomiting
  • increased abdominal distention
  • constipation
  • diarrhea
  • metabolic issues
  • blocked/clogged tubes
  • tube related issues
  • tube misconnections
38
Q

How is aspiration managed?

A
  • turn off fed immediately

- minimize incidence by raising HOB > 30 degrees

39
Q

How is nausea managed?

A
  • rate may need to be reduced, or feeding can be paused for 1 hour then re-started at reduced rate
40
Q

How is vomiting managed?

A
  • RD may re-assess type of tube placement
  • hold feeding if gastric feeding and emesis
  • consult MD for anti-emetic, and/or pro-motility agent
41
Q

How is increased abdominal distention managed?

A
  • turn off feeding, consult MD

- review bowel habit and last BM

42
Q

How is constipation managed?

A
  • meds that may contribute or manage constipation may need to be reviewed
  • may require fiber containing formula
  • may require additional water flushing
43
Q

How is diarrhea managed?

A
  • multiple medications can worsen diarrhea, so may need to be reviewed
  • rate of infusion may need to be re-assessed
  • may benefit from different formula with more or less fat or fiber
44
Q

What metabolic issues can arise?

A
  • hyperglycemia

- refeeding syndrome (food delivered too quickly)

45
Q

How are blocked/clogged tubes managed?

A
  • attempt to flush with 60 mL of room temp. water

- attain tube feed unblocking kit

46
Q

What are tube-related issues?

A
  • leakage
  • skin infection
  • tube dislodgement
47
Q

What is parenteral nutrition?

A
  • also called total parenteral nutrition (TPN)
  • infusion of a sterilized, specialized form of liquid nutrients through a vein into the bloodstream via an IV catheter
  • needs to be completely elemental
48
Q

What are indications for parenteral nutrition?

A
  • consistent with medical and patient goals
  • patients are unable to meet nutrition needs with EN
  • pre-operative support in the severely malnourished patient
  • gastrointestinal incompetency (paralytic ileus, small or large bowel obstruction unlikely to resolve within 5 to 7 days,
    severe diarrhea with evidence of malabsorption,
    intractable vomiting)
49
Q

What is peripheral parenteral nutrition (PPN)?

A
  • given through a peripheral vein
  • short term use - 7 days
  • limitations include: often unable to meet caloric needs, site must be rotated every 3-5 days, principle complication of thrombophlebitis
50
Q

What is central parenteral nutrition (CPN)?

A
  • infused into large central vein
  • greater percentage of caloric and protein needs can be met
  • more long-term
  • pharmacy compounds the solutions under aseptic conditions to prevent bacterial contamination
  • very important solution for CPN not put into PPN
51
Q

What are contraindications for TPN?

A
  • functional and usable GI tract
  • prognosis does not warrant aggressive nutrition support, or is not desired by patient or guardian
  • risks judged to be greater than benefits
  • TNP is more dangerous and expensive
52
Q

What are conditions necessitating TPN?

A
  • hyper-metabolic state with poor enteral tolerance and accessibility
  • ileus after major intra-abdominal surgery
  • hyperemesis gravidarum when jejunal feedings are unsuccessful
  • severely malnourished patients prior to and during an intensive intervention which precludes the use of the GI tract for at least seven days
  • patients undergoing high-dose chemotherapy, radiation and or bone marrow transplantation when EN is unsuccessful
  • severe acute pancreatitis where EN is unsuccessful
  • pre-operative support in the severely malnourished patient
  • supplemental TPN initiated when goal rate feeds cannot be achieved within 48-72 hours
  • supplemental TPN initiated on admission during diagnostic work up
53
Q

What is a PICC?

A
  • for CPN or medications
  • peripherally inserted central catheter
  • threaded to subclavian vein
  • tube is marked to ensure proper placement
54
Q

What is a PORT?

A
  • also for CPN
  • inserted into chest under the skin via minor surgery
  • the tube enters from the subclavian vein from the port site
55
Q

What are complications of TPN?

A
  • technical: pneumothorax, hemothorax, nerve injury, subcutaneous emphysema
  • mechanical:
    occlusion or fibrin sheath, thrombus
  • infections
  • metabolic: refeeding syndrome, hyperglycemia (hypoglycemia less common, but can occur)
    electrolyte or mineral abnormalities, hepatobiliary complications, metabolic bone disease
56
Q

What steps does a RD take before initiating TPN?

A
  • nutritional assessment
  • venous access evaluation
  • baseline weight
  • baseline lab investigations
57
Q

Once TPN initiated, what nursing actions should be taken?

A
  • monitor vital signs, temperature, ins and outs
  • check blood glucose
  • inspect catheter site for signs of inflammation, infection or bleeding and placement
  • visually check the solution/label (name, ID, expiry date, solution matches prescription, route of administration, leakage, emulsion stability)
  • maintain aseptic techniques with all procedures related to the setup and administration of TPN and catheter care (site, flushing, hub)
  • ensure TPN is delivered at the prescribed rate
  • monitor catheters infusion ability “stiff flush”
  • change IV q 24 hrs and with each administration of intermittent PN infusions
  • discard solution if it has not been used for >4 hours
  • check drug compatibility
58
Q

What is refeeding syndrome?

A
  • caused by rapid nutritional repletion in severely malnourished patients
  • characterized by fluid and electrolyte disturbances: hypernatremia, hypophosphatemia, hypokalemia and hypomagnesemia
  • can lead to fluid retention, heart and respiratory failure
  • symptoms: edema, cardiac arrhythmias, muscle weakness, confusion
  • monitor glucose, electrolytes, PO4 and Mg
    for 3 days
  • low serum levels must be corrected prior to feeding
  • feeds advanced slowly
59
Q

Considerations for stopping TPN?

A
  • wean TPN based on oral diet/initiation of enteral feeding
  • in hospital, slow to 1/2 rate, then stop when patient is meeting 50-60% requirements orally or EN
  • at home, decrease total calories/day or number of nights infused
60
Q

The overriding premise of nutrition support is…

A

If the gut works, use it

61
Q

The guiding principle of nutrition support is…

A

Use the least invasive and most physiologic method of feed; consider oral supplements, then EN, then PN

62
Q

What are the goals of clinical nutrition intervention?

A
  • to improve clinical status and outcome
  • to restore/improve nutritional status in the face of disease and injury
  • to possibly modulate/attenuate the disease process
  • to minimize the catastrophic effects of injury, sepsis and inflammation
  • minimize the rate of lean body mass catabolism and weight loss and work towards anabolism
  • provide essential nutrients (macro and micronutrients)
  • decrease infectious and non-infectious complications
  • reduce length of stay, costs
  • improve quality of life

Nutrition (21 decks)

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