Exam 4

START Erner

START Erner

In order for enternal nutrition to be used the patient must:

• have a functional GI tract

• exhaust oral diet methods first

Indications for enteral nutrition

• pts who cannot maintain adequate oral intake to meet nutritional and hydration requirements

• preventative - head/neck cancer

• treatment - malnutrition

• sufficient functioning GI tract for nutrient absorption

• can be able to safely place access - proper environment

Why is enteral feeding (G-tube) use controversal in long term care?

effects of G-tubes on long-term outcomes are unclear

True or false. G-tubes are beneficial with regard to preventing or healing pressure ulcers

false. not shown to be beneficial

in dementia, enteral feeding is associated with ______ and/or _____ ____. and it has ___ shown improvements in survival or quality of life.

anorexia

weight loss

not shown

What does the American Geriatrics Society recommend for dementia feedings? Problems with this approach?

careful hand feedings recommended

but the patient must have care access to use this method

Relative contraindications for enteral nutrition

• severe hemodynamic instability — reduced intestinal blood flow

• ileus — temporary slowing of digestive track → blockage

• vomiting/diarrhea — unable to absorb nutrtition properly

• upper GI bleeding — bowel ischemia

Absolute contraindications for enteral nutrition

• bowel obstruction — non functional gut

• major GI ischemia — non functional gut

• high-output fistual —gastric fluid leaking → could lead to nutrtion not being absorbed and nutrition being put in different parts of the body

the larger the size in French (Fr) the ____ the diaeter of the tube.

larger

_____ tubes can clog easier

smaller

for most patients, enteral nutrition is delivered into the _____ which is _____ feeding.

stomach

gastric

advantages of gastric feeding

• normal physiology

• improved ability to buffer gastric acids compared to post-pyloric

• stomach can tolerate larger volumes of feeds

disadvantages of gastric feeding

• cannot be used for patients with delayed gastric emptying, severe GERD, or those at risk for aspiration

Post-pyloric definition

after stomach

Higher risk for aspiration:

• dysphagia

• altered consciousness

• GERD

• antamonical abnormalities

• neurommuscular disorders

Where are the terminal points for post-pyloric feedings?

duodenal

jejunal

indications for post-pyloric feeding

• patients with high aspiration risk, severe GERD, recurrent n/v, gastric bowel dysmotility

Which type of feedings are pump-assisted

post-pyloric

why must post-pyloric feedings be given continuously or intermittedly?

low tolerance to large volumes of feedings

Disadvantages of post-pyloric feeding

• difficult tube placement

• smaller tube = increased risk for clogging

• difficult to maintain position of tube

• tube feeding tolerance difficulties → dumpting syndrome

tube based through the mouth and into the stomach

orogastric tube

indications for orogastric feeding

• premature and small infants → NICU

• not tolerated by alert patients

  • tubes may be damaged by teeth

  • gag reflex

tube inserted through the nasal passage into the stomach

nasogastric tubes

indications for nasogastric tubes

• short term feedings

• intact gag reflex — prevent aspiration

• gastric function not compromised

• low risk for aspiration

• may be placed for decompression → bowel obstruction

advantages of nasogastric tubes

• ease of placement

• surgery not required

• accommodates various administration techniques

disadvantages of nasogastric tubes

• increase risk of aspiration (tube terminates in stomach) → higher risk for gastric ileus patients

• not for patients with compromised gastric function

• may promote nasal necrosis, esophagitis, sinusititis

• visiblility impacts quality of life

tube instered through the nasal passage through the stomach into the duodenum or jejunum

nasoduodenal and nasojejunal

indications for nasalduodenal and nasojejunal

• high risk for aspiration since its past the stomach

• compromised gastric function

  • gastric outlet obstruction

  • severe reflux

  • gastropareisis

  • pancreatitis

organize the following in where they terminate, first-last:

• nasoduodenal

• nasonjejunial

• nasogastric

1. nasogastric

2. nasoduodenal

3. nasojejunal

advantages of nasoduodenal and nasojejunal feedings

• initiation of early enteral feeding → bypass stomach

• decrease risk of aspiration

• surgery not required

disadvantages of nasoduodenal and nasojejunal feedings

• post-pyloric tube placement is difficult

• continuous feedings only

• risk of nasal necrosis, esophagitis, or sinusitis

• drug absorption considerations

• quality of life

____-tube must be placed surgically and has 2-3 ports

Gastrostomy (G-Tube)

_____-tube must be surgically placed and has 1-2 ports

Percutaneous endoscopic gastrostomy (PEG-tube)

gastrostomy and PEG tubes go into the _____ whereas jejunostomy goes into the ____.

stomach

jejunum

Gastrostomy and Jejunostomy are placed through the _____ wall directly into the ____ or ____.

abdominal wall

stomach

jejunum

complications of gastrostomy and jejunostomy

leakage

tube dislodgement

clogging

Review: which enteral accesses can be placed at bedside

nasogastric

orogastric

nasoduodenal

nasojejunal

Review: which enteral access types are for long term EN duration

Gastrostomy

Jejuostomy

_____ enteral nutrtition is preferred for patients who are critically ill, malnourished, at risk for refeeding syndrome, or have poor glycemic control and requires a feeding pump

continuous

_____ tubes can only recieve continuous feeds

jejunostomy

____ feeding is preferred in home or community settings, provide total calories in <24 hours, and facilitates mobility during the daytime

bolus

_____ feeding is continuous infusion that is held during certain periods of time

intermittent

standard enteral feeding formulations are…

most common for normal digestive systems

elemental or peptide-based feedings are…

higher in protein and used for imparied digestive systems but are more expensive

explain disease specific enteral feedings

feedings based on whatever disease state you are trying to cover

what should be monitored with enteral feedings and why?

diarrhea

• common with enteral feedings

• what for medications that may worsen diarrhea

Metabolic — check electrolytes

• hyperglycemia

• micronutrient deficiencies

• refeeding syndrome

  • patients that previously had malnutrition are at highest risk

  • Hallmark sign — hypophsphatemia

Drug-nutritional interactions

explain insertion enteral device complications and how to avoid

• confirm placement before using

• GI perforation risk

• those at high risk should be radiologically placed

what infection risks are there with enteral device complications

sinusitis — nose insertion

ostomy site infection — ostomy tubes

how should you manage clogged tubes according to ASPEN?

warm water 30-60mL

which tablets should NOT be crushed and administered through enteral feeding tubes

SL tabs

SR tab/caps

Enteric coated tabs

for solid dosage forms that are appropriate to crush you should…

prepare as fine powder

mix with 15-30mL of water before admin

what ingredient should be noted and monitored for liquid formulations used in Enteric feeding tubes?

sorbitol

too much can cause side effects

generally, medications should be administered ___ minutes before or after enteral feedings

30

concerns for medications administed into jejunal tubes

pH

delivery beyond site of absorption (before jejunum)

reduciton in time for absorption along GI tract

for phenytoin ___ in enteral nutrition can reduce bioavailability, feeds should be held ____ hours before and after administration

salts

1-2 hours

considerations for enteral feeding on warfarin

vitamin K contents may affect INR

Floroquinalones and tetracyclines have potential for reduced bioavailability becuase of ____ and ____ cations in enteral feeds. Hold feedings __ hour before and after admin. avoid ___ admin.

divalent and trivalent

1 hour

jejunal

for PPIs admin can be complicated by ______ medications

acid-labile

enteral vs parenteral nutrition

enteral

• decrease in infectious complications

• more physiologic

• less costly

END Erner

START Carstens

____ of total body fluids live in the intracellular space

60%

early fetuses contain ___ body weight from water

90%

preterm infants have ___-___% weight from water

75-80%

termed newborns have ___% body weight thats water

70

____% for those 1 year and older of weight from water, only ___% once 80 or older

60

50

water within the cells

contains 40% of the body weight

rich in electrolytes (K, Mg, Phos)

intracellular fluid

2 compartments

• intersititial

• intravascular

water outside the cells

contains 20% of the body weight

electrolytes (Na, Cl, Bicarb)

Extracellular fluid

_____ is total body water loss whereas ____ is more extreme and is a reduction of extracellular fluid volume

dehydration

hypovolemia

___ - ____ % of total body water is replaced everday

5-10%

normal water intake from fluids is ____mL

normal water intake from food is ____mL

normal water from internal metabolism is ___mL

1500mL

500mL

400mL

the skin gets rid of ___mL of fluid per day

normal stool gets rid of ____mL of fluid per day

450mL

100-200mL

sorbitol can cause dehydration via…

flushing

true or false. you can still use oral rehydration methods while the patient is vomiting

true!

normal urine output is ___mL/kg per hour

0.5mL/kg

signs of moderate dehydration

• sunken eyes

• dry mucous membranes

• decreased skin turgor

• dark colored urine

• decreased urine output

• tachycardia

• delayed capillary refill ~2-3 seconds

signs of severe dehydration

• hypotension

• cold extremities

• lethargy

• deep and rapid respirations

• delayed capillary refill >3 seconds

the frank starling curve helps indicate when fluid boluses should be administered, what physical test can you use to determine that a person is responding to fluid?

passive leg raises

• leg raised 45 degrees

• blood pressure cuff on leg → if there is a change = fluid response

what factors should fluids have when used in fluid resucitation?

• remains intravascular

• predictably increase intravascular volume to restore hemodynamics

• minimal electrolyte changes

• readily available

• cheap

Fluid resuscitation fluids of choice

NS

LR

fluid resuscitation estimation for adults is ___-___ mL/kg/day or ____mL/m²

30-35mL/kg/day

1500mL/m²

For pediatric fluid resuscitation

<10kg at least ___mL/kg/day

10-20kg ADDITIONAL __mL/kg/day

>20kg ADDITIONAL ____mL/kg/day

100mL/kg/day

+ 50mL/kg/day

+ 20mL/kg/day

explain the 4-2-1 rule for maintenance fluid

4mL/kg first 10kg

2mL/kg additional 10kg

1mL/kg additional over 20kg

for patients with sepsis there must be a ____mL/kg bolus over the first 3 hours

30

True or false: fluids should be isotonic to the blood to avoid more fluid shifts when doing fluid replacement

true

explain how D5W is both iso and hypotonic

when entering the body it is isotonic

but when Dextrose is used the liquid is left and it can become hypotonic in the cells

due to the higher surface area of pediatric patients, they lose water _____ through the skin than adults.

faster

severity of pediatric dehydration is based on ___g of weight loss = 1mL of water loss

1gram

mild pediatric dehydration %

moderate pediatric dehydration %

severe pediatric dehydration %

mild = 3-5%

moderate = 6-9%

severe = >10%

calculation for percentage of weight loss from dehydration in pediatrics

(preillness weight - illness weight) / (preillness weight) *100

1-2 gorelick score = ___ rehydration

3-6 gorelick score = ____ rehydration and ____

>7 gorelick score = ____ rehydration only

oral

oral rehydration and reassessing in 30 minutes for adequate intake

IV rehydration only

preferred type of rehydration in mild to moderate dehydration

oral rehydration

concentration of oral rehydration solutions should be ___-___ mOsm with equal ____ to ____.

200-300

sodium to glucose

avoid ____ in patients <1 year old

freewater

for mild dehydration for pediatrics you do ____mL/kg over 4 hours at home

for moderate dehydration for prediatrics you do ____mL/kg over 4 hours at home

50mL/kg

100mL/kg

if vomiting occurs during oral rehydration you…

resume rehydration 30 minutes after vomiting

when are maintinence fluids started after rehydration?

after first 4 hours

for severe hydration IV fluids must be inititated at ___mL/kg over 10-15 minutes

20mL/kg

once volume resuscitatin is completed for severe dehydration patient should be started on ___mL/kg of ____ rehydration for 4 hours

100mL/kg

oral

adjunct medication for oral replacement therapy that improves tolerance and reduces immediate need for IV fluids (one time dose)

ondansetron