Term
| What is the maximum hang time for reconstituted powder formulas or formulas in which modular components have been added? |
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Definition
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Term
| What are appropriate interventions if delayed gastric emptying is suspected? |
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Definition
- Reducing or discontinuing all narcotic medications
- Switching to a low-fat or isotonic formula
- Administering the feeding solution at room temperature
- Reducing rate of infusion by 20-25 mL/hr
- Changing infusion from bolus to continuous
- Administering a prokinetic agent such as metoclopramide or erythromycin
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Term
| What should be done if nausea or vomiting occurs as the rate of administration or bolus volume of EN increases? |
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Definition
| The rate should be reduced to the highest tolerated amount, with an attempt to increase the rate again after symptoms abate |
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Term
| What should be done with an enterally-fed patient with nausea and abdominal distension? Why? |
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Definition
| GRVs should be monitored before each bolus or every 4 hours for continuous feeds. Although elevated GRVs alone do not always correlate with poor tolerance, the combination of an abnormal abdominal exam and elevated GRVs may be significant |
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Term
| What should be done if an enterally-fed patient complains of nausea despite having normal GRVs? |
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Definition
- Anti-emetic medications may help
- Patient should be checked for obstruction or fecal impaction, and sometimes even diarrhea
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Term
| How is abdominal distension diagnosed? |
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Definition
| Visual inspection and palpation as well as objective reports. Careful clinical observation is preferred over objective measures. |
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Term
| What should be done if an enterally-fed patient has abdominal distension (but not nausea/vomiting)? |
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Definition
- Abdominal x-ray to confirm appropriate intestinal anatomy and motility
- If intestinal appearance and function are normal, EN may be continued despite distension
- Feedings may need to be discontinued if motility is poor or if the bowel is markedly dilated
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Term
| What are clinical manifestations of maldigestion? |
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Definition
- Bloating
- Abdominal distension
- Diarrhea
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Term
| What are diagnostic studies for malabsorption? |
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Definition
- Screening: gross and microscopic examination of stool. Can include measuring fat/protein content.
- Intake-output balance: stool collections for quantitative fecal fat study.
- Maldigestion-malabsorption of specific nutrients
- Endoscopic small bowel biopsy
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Term
| What are common causes of maldigestion/malabsorption? |
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Definition
- Gluten-sensitive enteropathy
- Crohn disease
- Diverticular disease
- Radiation enteritis
- Enteric fistulas
- HIV
- Pancreatic insufficiency
- Short gut syndrome
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Term
| What are the criteria for diarrhea? |
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Definition
- >500 mL stool output in 24 hours
- More than 3 stools per day for at least 2 consecutive days
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Term
| How can stool volume be measured? |
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Definition
- Placing a collection device in toilet or using a bed pan
- Using a rectal tube or by placing a pad under the patient and weighing it after each stool
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Term
| What are common causes of diarrhea in EN patients? |
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Definition
- Medications (particularly liquid medications with a sorbitol base, antibiotics)
- Infection (C diff and nonclostridial bacteria)
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Term
| How can hypertonic drugs (such as those containing sorbitol) and those which irritate the gut (potassium) be administered to EN patients, and why? |
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Definition
| They should be diluted to avoid inducing dumping-like syndrome |
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Term
| Should EN patients with diarrhea have their formula diluted with water? Why? |
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Definition
| No. It has not been shown to improve tolerance and it may contaminate the formula. |
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Term
| What is the process for managing diarrhea in EN patients? |
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Definition
- Medical assessment of the patient to rule out infectious or inflammatory causes, fecal impaction, problematic medications
- Change of formula type
- Addition of soluble fiber
- Use of an antidiarrheal agent once C diff has been ruled out
- Continuation of EN as tolerated and transition to partial PN if necessary
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|
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Term
| Which patients should be suspected of bacterial overgrowth? |
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Definition
- Roux-en-Y
- Those with altered GI anatomy
- Those who have been treated with prolonged antibiotics with abdominal symptoms and/or catabolism/hypoalbuminemia
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Term
| How should powdered EN formulas be prepared to reduce risk of contamination? |
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Definition
| They should be prepared with sterile water in a clean environment |
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Term
| What can be done if there is excess formula left after maximum hang time is reached? |
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Definition
The remainder can be refrigerated immediately and stored according to manufacturer's recomendations. Note: the volume the is given to the patient should only be the maximum voume that can be used in the given hang time. The rest should be separated IMMEDIATELY and refrigerated for future use (not placed in the patient's room).
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Term
| What should be done to minimize risk of contamination when pouring EN formula from cans into a feeding bag? |
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Definition
| The lids should be cleaned with isopropyl alcohol and allowed to dry before the formula is poured into the bag |
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Term
| How often should the feeding bag itself be changed in a closed system? |
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Definition
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Term
| What should be done to prevent EN contamination after GRVs have been checked? |
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Definition
| Gloves must be removed and hands must be washed, followed by donning of clean gloves |
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Term
| What can be done to prevent a patient's microorganisms from migrating into the tube feeds? |
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Definition
- Drip chamber
- Formula should not remain in delivery system if feeds are not being run
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Term
| What is the clinical definition of constipation? |
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Definition
| Accumulation of excess waste in the colon, often up to the transverse colon or even the cecum |
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Term
| How can uncomplicated constipation be differentiated from small bowel obstruction or ileus on x-ray? |
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Definition
| With uncomplicated constipation, there is rarely any small bowel dilation |
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Term
| Is chronic stimulant use (e.g. senna) recommended for those with constipation? |
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Definition
| No, because it can result in tachyphylaxis. Chronic stool softener use is OK. |
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Term
| How much fluid should EN patients on a fiber-containing formula receive? Why? |
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Definition
| AT LEAST 1 mL/kcal to prevent constipation |
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Term
| How can fecal impaction present in the elderly? |
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Definition
|
|
Term
| What symptoms does fecal impaction present with? |
|
Definition
| Fecal impaction should be suspected when stool volumes are small and then become liquid |
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Term
| How does risk of aspiration relate to oropharyngeal secretions, gastric secretions, and GRV? |
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Definition
| Pulmonary aspiration can occur with inhaling of secretions, but it has never been consistently proven to be a consequence of high GRVs |
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Term
| What are risk factors for aspiration in EN patients? |
|
Definition
- Low head of bed elevation
- Vomiting
- G-tube feedings (as opposed to small bowel feeds)
- Low Glasgow coma score
- GI reflux disease
- Malpositioned feeding tube
- Transportation within hospital
- Inadequate nursing staff
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Term
| Can patients with dysphagia develop aspiration PNA regardless of gastric contents? |
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Definition
| Yes, by aspirating oropharyngeal secretions |
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|
Term
| Is use of glucose oxidase strips recommended for detecting aspiration of gastric contents? |
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Definition
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|
Term
| How should aspiration of gastric contents be detected? |
|
Definition
| A patient who develops dyspnea, cyanosis, and agitation associated with a new infiltrate on chest film should be presumed to have aspiration |
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|
Term
| How should GRVs be used when monitoring enteral tolerance? |
|
Definition
| They are a measure of tolerance but should NOT be used in isolation |
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|
Term
| How does metabolic acidosis/alkalosis affect serum potassium levels? |
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Definition
| Metabolic acidosis can cause hyperkalemia. Metabolic alkalosis can cause hypokalemia. |
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Term
| How should hypercapnia be addressed in regards to enteral feeding? |
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Definition
| Provide maintenance energy needs only until hypercapnea resolves |
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Term
| What are the risk factors for thiamine deficiency? |
|
Definition
- Chronic alcoholism
- Advanced age
- Long-term malnutrition
- Malabsorption
- Antacid therapy
- Dialysis
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|
|
Term
| Not receiving which type of fatty acid causes EFA deficiency? |
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Definition
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Term
| What is an easy way to identify dehydration in the elderly? What are the limitations? |
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Definition
| Tongue dryness is a reliable way to identify dehydration in the elderly, provided that medication-induced dryness is ruled out |
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Term
| What laboratory levels are suggestive of dehydration? |
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Definition
| Elevated BUN, plasma osmolality, and hematocrit (sodium can be elevated, low, or normal) |
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Term
| How does muscle mass affect creatinine? What are the clinical implications of this? |
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Definition
| A patient with a very low muscle mass may have a very low baseline creatinine. Thus, a very small increase in creatinine may signify a large decrease in GFR. |
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Term
| How is BUN affected by protein intake? What are the clinical implications? |
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Definition
| BUN reflects protein intake as well as state of hydration and renal function. A patient with no protein intake and renal failure may still have a relatively low BUN. |
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Term
| How can specific gravity and urine output volume reflect dehydration? What alternative measures are there? |
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Definition
| A high specific gravity and low urine output reflects dehydration. Urine color is also an effective, although less precise, measure of hydration. |
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Term
| What is an appropriate amount of urine output for adults? |
|
Definition
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|
Term
| How should fluid needs be altered by fever? |
|
Definition
| Increase fluid intake by 12% per degree celsius above 37.8 degrees C |
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|
Term
| How does glycemic control influence fluid needs? |
|
Definition
| Patients with hyperglycemia require more fluid |
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|
Term
| How does lactation affect fluid needs? |
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Definition
| Lactating women have increased fluid needs |
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