Enteral Feeding Flashcards
(75 cards)
1
Q
name the 6 steps of nutrition and dietetic care
A
- assessment
- nutrition and dietetic diagnosis
- strategy
- implementation
- monitor and review
- evaluation
2
Q
What questions do you need to think about to justify EN?
A
- why are they on EN in the first place?
- what is their nutritional status like
3
Q
Key considerations for EN (4)
A
- clinical condition, indications for EN, nutritional status and treatment plan
- route of EN
- Feeding regimen (including timing and type of feed)
- specific monitoring plan
4
Q
What specifically needs to be considered in EN monitoring plan? (5)
A
- safeguarding
- complications
- how to determine effectiveness of intervention
- safety
- early detection of complications
5
Q
What classifies someone needing EN for malnourishment
A
- BMI <18.5 kg/m2
- unintentional weight loss >10% in 3-6 months
- BMI <20 kg/m2 AND unintentional weight loss >5% in 3 - 6 months
6
Q
What classifies someone needing EN - at risk of malnourishment?
A
Even with a high BMI unintentional weight loss >10% = malnourished
- Little to no intake for the last 5+ days
- Little/no intake likely in the next 5+ days
- Poor absorptive capacity
- high nutrient losses (i.e. high output fistula)
- increased nutritional needs i.e. catabolic, cancer cachexia
7
Q
Name some situations where EN may be indicated: (10)
A
- oral intake insufficient (food fortification and oral nutrition support)
- unconscious patients
- neuromuscular swallowing disorders (stroke)
- physiological anorexia
- upper GI obstruction (head and neck cancer)
- GI dysfunction or malabsorption (pancreatitis, GI dysmotility)
- increased nutritional requirements (cancer cachexia)
- psychological problems (anorexia nervosa/ eating disorder/ ARFID)
- specific treatment (Crohn’s and Ulcerative colitis)
- unsafe (dysphagia)
8
Q
Assessment considerations: Anthro
A
- BMI
- % weight loss in what period of time
- hopefully referred using a MUST tool - a screening tool NOT assessment tool
9
Q
Assessment considerations: biochem
A
- Refeeding syndrome
- dehydration
- disease specific/condition
10
Q
Assessment considerations: clinical
A
- underlying condition
- medications
- medication side effects/impact on nutritional status
- some medications will affect timings of feed and water flushes
- potential drug / nutrient interactions
11
Q
Assessment considerations: dietary
A
- recent oral intake
- recent nutritional intake and prospective intake
12
Q
Assessment considerations: environmental and functional
A
- living situation
- social support
- impact of condition
- mobility
12
Q
Assessment considerations: environmental and functional
A
- living situation
- social support
- impact of condition
- mobility
13
Q
NICE CG32 definition of malnutrition:
A
Malnutrition is a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome. In this guideline, we do not use the term to cover excess nutrient provision.
14
Q
Are patients on EN always exclusive EN?
A
no. When long term, sometimes need to be weaned off the tube.
If the gut is working - USE IT
15
Q
Nutrition and dietetic diagnosis - what goes in it?
A
Problem:
- the nutritional problem identified through the assessment
- what the dietitian aims to change
e.g. insufficient/inadequate oral nutrition intake OR unsafe swallow
Aetiology:
- The underlying reason for the problem identified
e.e. stroke/ neuromuscular swallowing condition/ increased nutritional requirements
Signs: CAN BE MEASURED
- objective evidence of disease; manifestations of disease perceivable by health worker
e.e. recent weight loss >10% in past 3/12; BMI <18.5 kg/m2
Symptoms: SUBJECTIVE/ REPORTED PT EXPERIENCE
- manifestation of disease perceivable to the patient themselves
e.e nausea, pain, discomfort, feeling weak
16
Q
Who makes the decision to EN feed?
A
Doctor or consultant in charge of patient’s care.
17
Q
What source of extra info about patient history is useful?
A
MDT notes and information from the referrer
18
Q
what does the strategy need to address?
A
the problem
19
Q
Strategy; what considerations in EN? (3)
CRUCIAL QUESTIONS IN CLINICAL DECISION MAKING PROCESS
A
- how long (weeks) wukk th patient be EN fed?
- Which feeding route being used (NG, NJ, PEG, PEJ)
- Where is the tube going to? (stomach or jejunum)
20
Q
What are the aims to meet nutritional requirements with EN?
A
- partial or full needs met?
- type of feed
- duration and timing of feeds
- Nutritional adequacy of feeds
21
Q
Strategy - how could you measure outcomes?
A
- weight maintenance
- weight gain
- prevent further weight loss
22
Q
What method would you use short term (and duration)
Long term (and duration)
how are they placed?
A
short term = NG <4-6 weeks
Long term = PEG, PEJ or NJ (through abdomen all) - placed by gastronomy
Feed differently if going through stomach or straight to intestine
23
Q
When feeding into stomach why can you feed at a higher rate? what rate?
A
because of pyloric sphincter acting as a gateway to intestine therefore increased rate and be better tolerated
up to 150 ml/hour
24
when feeding into jejunum what rate do you feed? and why?
Less than into stomach because bypassing pyloric sphincter.
top rate of feed = 75 ml/hour
25
What are risks associated with NG feed? why? safety measures to take and how?
1. high risk of moving
2. high risk of aspiration
3. confirm placement by syringe to test what's in the stomach using litmus paper
pH <4 = stomach acid
pH 6-7 = lungs
CONFIRMING PLACEMENT WILL ALWAYS BE PART OF THE INSTRUCTION TO MEDICAL TEAM BEFORE EVERY FEED
sending home with NG = high risk for these reasons but some people can manage it safely
26
what is buried bumper syndrome? how do you prevent?
when the stomach wants to heal the wound and grows back over the bumper (PEG tube)
very serious = can cause infection, damage and mortality
prevention = rotate it 360º, insert it further in and out by 1cm as daily part of tube care - called advancing it
NEVER FOR PEJ because of highly specific placement
27
how long can a PEG tube last?
7 + yrs
28
how often does a balloon gastronomy tube last? what are benefits?
specific treatment instructions needed?
1. needs replacing every ~3 months
2. lower risk of buried bumper syndrome
3. can be replaced at home by nutrition nurse
4. same daily management as PEG
5. instruct nurse to fill balloon with water because it deflates by osmosis in the stomach.
29
describe ENfit and benefits of it?
ENfit= standardised enteral feeding device connecter:
1. designed to ensure feeding connectors cannot be used for other unrelated infusions
WHY? because using the incorrect route for medications is listed as a NEVER EVENT in NHS (2018)
2. improves patient safety by preventing misconnections between systems
3. ENfit ports = shaped differently to lier-lip or catheter ports according to ISO specifications
benefits:
1. reduces unrelated infusions, i.e. medications = improved patient safety (NEVER EVENT)
30
How often are water flushes advised? why? what other considerations needed?
1. 4-6 times a day before AND after feed & meds
2. minimum amount for a flush = 30 ml
3. contributes to meeting fluid requirements
4. in hot weather extra fluid and sweating need accounting for
5. if at risk of fluid overload CANNOT go over fluid requirement (i.e. kidney disease, congestive heart failure) so aim for calculated needs
31
When can you NOT overfeed protein AT ALL?
some can have complications from overfeeding protein
1. kidney disease
2. diabetic nephropathy
32
Meeting nutritional requirements: calculating needs how?
same as any other patients.
Kcal and Protein = most paramount nutrients to meet appropriately
Remember fluids!
PENG = inpatients
HENRY = outpatients even if on EN
EFSA
33
Meeting nutritional requirements: choosing appropriate feed - how?
1. consider patient's previous experience with EN
2. fluid restrictions: use increased caloric density feeds
3. high protein requirements = use higher protein feed
34
Implementation plan: what needs to be included specifically for EN?
1. medical notes will reflect your feeding plan
2. specific instructions on TIMING, VOLUME AND RATE OF FEED
3. specific instructions on water flushes and medications
4. initiating feeds - local policy.
5. Consider risk of referring - this needs close monitoring until stable
example:
PEG = 1st hr, nothing
next 4-8 hours = water flushes only to check working properly
Then initiate at a low rate = 20 ml/hour and increase rate at 20 ml/hr every 4 hours until goal is reached.
35
What impacts number of hours feeding?
1. bed bound and not tolerating feed well = feed at slower rate
2. If doing rehab or up and about a lot in the day - feed across 8 hours is more appropriate
36
Implementation: consider drug nutrient interaction, why?
patient might need a specific time break before or after medication administration.
check with pharmacist - they're a wealth of knowledge
if there is not enough time for the complete feed to finish within these time restrictions - speak with medical team.
37
How would you calculate feed duration per day?
1. calculate nutrient needs
2. identify correct feed and how much is needed per 24 hr
3. calculate goal rate within specified hours i.e. 1500 mL/20 hr = 75 mL/hr
4. calculate fluid for water flushes i.e. 1680 mL - 1500 mL = 180 mL so; minimum water flush = 180 mL/ 30Ml = 6 flushes.
38
Implementation - who am I going to instruct and why?
1. doctor - prescribing, medical management
2. nurses - clear instructions because they implement the plan
3. pharmacy - prescribing, drug nutrient interactions
4. enteral feeding company - whoever manages orders and stock
5. Catering - is the patient not having oral food (NIL BY MOUTH) or specific foods only? Think safety
6. speech and language therapist - monitoring progress to oral nutrition (i.e. dysphagia)
7. other dieticians - managing caseload
8. THE PATIENT - communication is important, negotiation, explain what you're doing and why. Helps figure out what feeding regimen is more appropriate for them.
39
what does NPO mean?
nil per ost - i.e. nil by mouth
40
unblocking tubes - what to never do?
unblock with Coca Cola because wears the tube out, creates a high sugar environment promoting bacterial growth and increases infection risk
41
When instructing nurses what to include?
type of red
rate
duration
water flushes
42
Caring for stomas and tubes: preventative measures for complications (8)
1. daily cleaning and hand hygiene
2. routine stoma care
3. advancing tube and rotating
4. ensure upright position
5. titrate volumes
6. titrate feeds, match fibre
7. provide fluids +/- fibre
8. flush before and after use, do not co-administer feed/meds, do not use crushed meds
43
Stoma and tube care problem - how do you fix it? infection at stoma site
topical antibiotics, dressings
44
Stoma and tube care problem - how do you fix it? over-granulation tissue
check position, dressings
45
Stoma and tube care problem - how do you fix it? buried bumper
re-site tube
46
Stoma and tube care problem - how do you fix it? aspiration
reduce rate / prokinetics
47
Stoma and tube care problem - how do you fix it? nausea/vomiting
check meds, reduce volume; change rate of feed
48
Stoma and tube care problem - how do you fix it? diarrhoea
check meds, modify feed, lower osmolality feed
49
Stoma and tube care problem - how do you fix it? constipation
modify feed, advise re meds, higher osmolality feed; are they getting enough fluid and fibre
50
Stoma and tube care problem - how do you fix it? tube blockage
flush with warm water + massage, flush with clog-zapper/PERT, replace tube
51
hat measure to take to prevent aspiration? (4)
fed at >30º angle to keep feed going down correct way in the right place.
If aspiration occurs, reduce feed rate
use prokinetic meds to increase rate of peristalsis
can adde extension of jejunostomy tube to reduce aspiration risk
52
Name 2 pro kinetic medications
1. erythromycin
2. metoclopramide
53
describe granuloma? Who can help monitor?
very red vascular tissue for wound healing
grows upwards instead of healing flat
prevention to keep it clean and daily rotations
tissue viability nurse can help manage/monitor
54
what to include in instruction for EN?
1. tube placement checks
2. flushes
3. manage and monitor infection risk with cleaning and hand hygiene
4. how to unblock a tube and when needed
5. tissue viability checks
6. rate of feed, type of feed and when to feed (which hours in the day)
7. monitoring aspiration risk
8. tube maintenance, ie balloon gastronomy - re inflate with water to keep full
9. tube life span and when to change
55
What does HEN stand for?
home enteral feeding
56
Dietetic monitoring of EN patients - what to monitor (8)
1. nutritional intake
2. anthropometry
3. clinical chemistry
4. clinical condition
5. medications prescribed
6. gastro intolerance
7. feeding device
8 nutritional goals and outcomes
57
Dietetic monitoring: rationale and how? Nutritional intake
how?
food charts, fluid charts, patient reporting
rationale:
compare prescribed with delivered volume of feed
prevent over/underhydration
energy/electrolyte content in context of IV/enteral feeds
58
Dietetic monitoring: rationale and how? anthropometry
how?
weight
BMI
MUAC
handgrip dynamometry
rationale: monitor changes in nutritional status
59
Dietetic monitoring: rationale and how? clinical chemistry
how?
biochemistry
haemotology
rationale:
hydration status
metabolic stress
nutrient deficiencies
metabolic abnormalities
60
Dietetic monitoring: rationale and how? clinical condition
how?
consciousness
swallow status
temperature (pyrexia)
rationale:
appropriate role of access
changes may affect nutritional requirements
61
Dietetic monitoring: rationale and how? medications prescribed
how?
drug charts
(BAPEN source or Irish society for clinical nutrition and metabolism source) for drug nutrient interactions
rationale:
side effects and tolerance
drug-nutrient interactions
timing of enteral tube feeding
appropriate formulation of medications
tube blockage risk
62
Dietetic monitoring: rationale and how? gastrointestinal tolerance
HOW?
stool charts
gastric residual volumes
ask patient
rationale:
bowel functions and tolerance of feed
gastric emptying and appropriateness of feed
63
Dietetic monitoring: rationale and how? feeding device
how?
position and condition of feeding tube
site of tube insertion
Rationale:
position of feeding tube (mindful of never events)
signs of infection/irritation
leaks/cracks in tube
64
Dietetic monitoring: rationale and how? Nutritional goals and outcomes
How>
specific goals set
rationale:
check progress with goals
clinical effectiveness of intervention
65
why is communication and good rapport integral to EN patient care?
1. understand and empathise with difficulties and effect on quality of life (i.e. missing food, social situations)
2. communicate what you're doing and why - negotiate plan with the patient - improves adherence
3. mindful of nut allergies and fat emulsions (vegetarian, meat, fish proteins) look at ingredients
4. ensure patient gets info in writing (plain language)
5. accommodate lifestyle preferences (veggie/vegan) cultural and religious aspects of diet/life
66
name 3 stages at which drug nutrient interactions can be influenced by nutrition and how?
1. transport from gut to lumen to intestinal enterocytes - can be followed by presystematic metabolism prior to absorption in blood
2. transport into the blood, usually bound by plasma proteins
3. deactivation by stage 2 metabolic process: oxidation by miscrosomal enzyme systems (i.e. cytochrome P450) ; conjugation with glucoronic acid, sulphate or glycine ; excretion of the conjugate in urine or bile
67
How can drug absorption be impacted by nutrition?
absorption can be delayed or enhanced by presence of absence of food (esp orally taken drugs)
68
how can presence of food in stomach impact drug absorption? (8)
1. delay gastric emptying
2. altered GI pH
3. binding site competition
4. chelation of drugs by food cations = reduce absorption of nutrient and drug
5. dietary fats impeding absorption of hydrophilic drugs
6. some drugs require empty stomach to take to maximise absorption rate and therapeutic effect
7. some need to be taken with food to achieved slower and more sustained absorption rate
8. fruit juice, tea or coffee can alter drug's pH balance and impact on properties
69
how can illness or nutrition impact drug transport - give example:
drugs = often transported by blood plasma proteins - severe malnutrition or disease can affect plasma protein synthesis reducing body's ability to transport drugs = lower effectiveness
e.g. liver disease = reduced synthesis of plasma proteins
70
what factors impact drug metabolism? (7)
1. deactivation or conjugation of a drug = alters pharmacological or toxic effects
2. short term starvation/nutritional inadequacy = influences drug effectiveness and safety
3. drug dose often determined by weight => sudden weight loss or dehydration can = overdosage
4. undernutrition = reduces activity of microsomal drug metabolising enzymes => diminish drug efficiency and rate of synthesis of active metabolite/ OR enhancing toxicity by reducing excretion rate
5. amount of water = affects drug metabolism = can be perturbed by dehydration or oedema including that associated with protein energy malnutrition
6. fat soluble drugs => absorption affected by increase or decrease of adipose tissue. impact varies depending on pathway of metabolism
7. increase of decrease in drug metabolism rates => impaired drug action or increase in side effects => dose may need adjusting to
71
Name 5 potentially SERIOUS drug nutrient interactions
1. warfarin & foods with vitamin K i.e. cranberry juice
2. grapefruit juice & fexofenadine or ciclosporin
3. ACE inhibitors/ARBs & potassium supplements or salt substitutes => can causes hyperkalemia
4. MAOIs & tyramine i.e. cheese, yeast extracts, soybeans, pickled herring, red wine => may increase blood pressure and palpitations
5. Isotretinoin & vitamin A = drug is a retinoid => vitamin A toxicity
72
what is clinical significance of drug nutrient interactions
1. interaction with drugs with narrow window of effect and toxicity i.e. lithium and anti-coagulants
2. meal pattern implications
3. need to be taken long term
4. necessitate diet restrictions
5. GI or appetite side effects
6. direct competition with a nutrient
73
factors that increase risk of drug nutrient interactions (6)
1. GI, renal or liver impairment
2. nutritionally compromised (alcohol or disease)
3. recent weight loss
4. dehydration
5. poly pharmacy
6. prolonged drug therapy
74
Who is most at risk of drug nutrient interactions? (3)
1. elderly
2. on EN
3. substance misuse
