Transcript Problem Prevention

ENTERAL NUTRITION
Emphasis on Nursing Care
A.S.P.E.N. Nurse Practice Section
Rebecca Bartlett, MSN, CNS, RN
Konni Hall, BSN, CNSC
Deborah S. Kovacevich, RN, MPH
Carol McGinnis, MS, CNS, CNSN
THE AMERICAN SOCIETY FOR PARENTERAL & ENTERAL NUTRITION
Enteral Nutrition
Emphasis on Nursing Care
• These slides were developed by the American
Society for Parenteral and Enteral Nutrition
(A.S.P.E.N.) Nutrition Support Nurses Practice
Section.
• They are intended to be used in their entirety to
disseminate information and enhance critical
thinking in the area of enteral nutrition.
• Information in this presentation will help to
facilitate the sharing of basic nutrition support
nursing knowledge with our colleagues in
general practice or in other nursing specialties.
Objectives
At the end of this presentation the learner should
be able to:
– Discuss indications, contraindications and rationale for
enteral nutrition (EN)
– Describe selection and placement of enteral feeding
tubes (EFTs)
– Design a patient-specific enteral feeding regimen
– List adverse effects of EN and strategies for
identification and prevention
– Discuss monitoring for effectiveness of EN
Enteral Nutrition (EN)
• Nutrition provided through the
Gastrointestinal (GI) tract via tube,
catheter or stoma that delivers nutrients
distal to the oral cavity
• First choice when oral intake is suboptimal
• “If the gut works, use it”
Enteral Nutrition
• Preserves gut integrity, modulates stress
response, attenuates disease severity and
helps maintain the immune system8, 27, 32, 34
• Decrease infection & morbidity with EN vs.
Parenteral Nutrition (PN)14, 18, 19, 27, 32
• Significant cost differential between PN
and EN
Contraindications
• Bowel obstruction or dysfunction (e.g.
ileus)
• Inadequate blood flow to the GI tract (e.g.
mesenteric ischemia/infarction)
• Proximal high output fistula
Situations Where Modifications to
feeding plan may be indicated:
• Gastroparesis
• Pancreatitis 15,21,22,23
• Chylothorax
True or False?
x
• The presence of bowel sounds are
necessary before initiating feeding
into the GI tract?
Assessment
• Assess current status
– Medical condition
– Physical status
• Assess nutritional status
– Nutritional history
– Current nutritional status
– Assess caloric, protein, fluid and specific
micronutrient, and electrolytes needs
Establish Plan
• Assess ability to meet estimated needs
• Assess patient goals, lifestyle, plans
• Anticipate length of need for EN
– Is it anticipated that oral intake can resume
and adequately meet needs soon?
– Is the need for continued feeding after
discharge anticipated?
Determining Best Feeding Location
– Gastric
• Requires functional stomach
• Possible to use bolus feeding
– Small Bowel- duodenal or jejunal
• May be indicated for gastric outlet
obstruction, gastroparesis, or increased risk
for aspiration
• For specific conditions, such as pancreatitis
– Gastric with Small Bowel Access (NG
& NJ, G &J or GJ tubes)
• Gastric decompression is indicated with
distal feed
x
Establishing Enteral Access
Nasal (or oral) tubes
– “Blind” placement
– Use of tracking device or other aids
– Endoscopic placement
– Fluoroscopic guidance
Abdominal tubes
– Surgical (open or laparoscopic)
– Endoscopic (PEG or PEJ)
– Fluoroscopic guidance
Feeding Tube Insertion Sites:
• Nasal
– Least expensive
– Easy to place
– Ideal for short term
– Contraindications: obstruction, coagulopathy,
basilar skull fracture, nasal/facial fractures
• Oral
–  risk displacement
• Esophagostomy
– May be done with ENT surgery
– Less desirable
Securing Tube in Place
Feeding Tube Insertion Sites:
• Abdominal: (gastrostomy, jejunostomy or
combination)
– Long term feeding
– Cosmetic advantages
– More secure if patient confused
– Contraindications: ascites, morbid obesity,
previous gastric or abdominal surgery, late
pregnancy; healing may be impaired if patient
receiving chemo and/or radiation therapy
Enteral Feeding Tube Placement
• Gastric placement used initially; tube advanced
based on tolerance
• Nursing has key role
• As tube advances to small bowel observe for:
– appearance of aspirates
– change in pH
• Electromagnetic transmitting device shown to be
helpful in small bowel tube placement
(3)
Assessing Feeding Tube
Placement
• Do not rely on auscultation alone
• Gold standard for proper placement is
radiographic confirmation
• Measure and mark exit area of tube to
help identify tube misplacement
Algorithm for Enteral Device
Selection
Enteral Nutrition Needed
Less Than 3-4 Weeks
Greater Than 3-4 Weeks
Nasoenteric
Feeding Tube
Long Term
Tube
Aspiration Risk
or Delayed
Gastric
Emptying
Nasoduodenal
or
Nasojejunal
Tube
No Aspiration
Risk or
Gastric
Problems
Aspiration Risk
or Delayed
Gastric
Emptying
No Aspiration
Risk or
Gastric
Problems
Nasogastric
Tube
Jejunostomy
or Combined
GastrostomyJejunostomy
Gastrostomy
Tube
Guenter & Silkroski, 2001, p. 53
Enteral Feeding Formula Selection
University of Michigan; Patient Food and Nutrition Services
Formula Administration
• Continuous feedings
• Initiation of feedings
– Using full strength formula, begin with 25-50% of needs
– Increase rate or volume to goal within 24-48 hours as
tolerated
• Monitor amount delivered
• Be aware of feedings held for tests, therapies, etc.
• May need to increase rate to ensure adequate
volume met
Scheduling for Patient
Convenience
• Bolus feeding
– Gastric placement only
– Delivered over length of time equal to a
“comfortable” meal
– May be administered immediately following
meal, vary volume on meal by meal basis as
patient transitions to oral intake
Intermittent Continuous Feeding
– Small bowel feeding
– Deliver over 10-12 hours
• Might taper gradually from 24 hour feeding
– May be adjunct to oral intake
– Patient preference may be night feeding
– Patients may not be hungry during the day if
complete needs met
Additional Fluid
• Additional fluid requirements:
– 1ml/kcal or 30 mL/kg
– Identify water provided by formula
– Meet additional needs with water flush or
bolus
• Assess for signs of dehydration
Problem prevention:
Aspiration Risk
Risk Factors
• Advanced age
• Bolus feeding
• High-risk disease or injury
• Tube malposition
• Mechanical ventilation
• Poor oral health
• Presence and size of nasogastric tube
• Sedation
• Supine position
• Vomiting
• Nurse staffing level
Aspiration
• Unless medically contraindicated, elevate the
head of bed (HOB) 30o - 45º
• Use reverse Trendelenberg if unable to elevate
the HOB
• Ensure or provide good oral hygiene
• Verify tube position before initiating EN
• Consider continuous infusion in high risk
patients or those exhibiting signs of intolerance [2]
• Administer motility agents and/or use postpyloric tube placement when gastric residual
volumes indicate poor gastric emptying
Food Safety Considerations
• EN provides ideal growth media for
microorganisms
• Organisms multiply rapidly in enclosed
environments
• Large numbers of pathogens can induce:
– abdominal discomfort, nausea, vomiting and diarrhea,
– other infections, including pneumonias and UTIs.
• Take measures to minimize the potential for
microbial growth
Potential Points for Contamination
From ASPEN Enteral Guideliens, 2009
Minimizing Microbial Growth
• Use closed systems whenever possible
• If “open” systems are used, follow hang time
guidelines and avoid “topping off” existing
product
• Establish clean work surface
• Avoid touch contamination
• Clean can tops and connection sites
• Follow safety guidelines for preparation and
handling of products and administration sets
Problem Prevention:
Microbial Growth
• Effective hand hygiene
• Utilize clean gloves and use
effective hand hygiene
between glove changes
• Cleanse with antiseptic agent
and water when potential for
Clostridium difficile exists as
alcohol-based agents may be
ineffective against the spores
Insert hand
Hygiene
picture
Formula Hang Time
From ASPEN Enteral Guideliens, 2009
Problem Prevention:
Hardwire Safety
• Label enteral feeding containers and related
equipment
• Take steps to prevent inadvertent
misconnections
• Imbed safety into EN order form
• Update Standard Operating Procedures
(SOPs) based on research & guidelines
• Follow national standards and safety
guidelines
Be sure all tubes “ARE FIT”
• Avoid standard IV Luer syringes
• Route tubes and catheters having different
purposes in different, standardized directions
• Educate non-clinical staff and visitors not to
reconnect lines
• Fight fatigue
• Identify misconnection potential
• Trace the tube/catheter from the patient to point
of origin
Problem Prevention:
Related To Feeding Tube
•
•
•
•
Tube migration/displacement
Site infection
Leakage
Clogging
Problem Prevention:
Inadvertent Tube Misplacement
• Nasally placed tube
– Secure tube
– “Out of site, out of
mind”
– Measure and mark
external portion of tube
at exit
– Consider feeding tube
bridle
Bridled feeding tube; secured
to cheek
Problem Prevention:
Inadvertent Tube Misplacement
Abdominally placed tube:
• Keep tube out of reach of busy fingers if
patient confused- tuck into clothing and/or
use abdominal binder
• Consider use of low-profile tube if patient
at risk for pulling longer tube out
• Consider periodic feedings
Problem Prevention:
Gastrostomy Tube
“Buried bumper” syndrome
• Cause: excessive traction or
tightness
• Internal balloon or external aspect
becomes imbedded into tissue
• Results in pain, cellulitis, drainage
at site, tube obstruction, and/or
peritonitis
Hexamer, B ref #11
Buried Bumper Syndrome
• Interventions:
– Release suture if too tight
– Measure external portion and document
– External bumper should rotate freely
– Place light layer of gauze comfortably
underneath external bumper
Problem Prevention:
Gastrostomy Tube
Tube migration
• Balloon can block the
pylorus
• Can result in outlet
obstruction
– Distention
– high residual volumes
– emesis
Vacek, ref #39
Tube Migration
• External bumper or disc will reduce
potential for migration
• Measure external portion and monitor daily
with site care
• Secure well to abdomen
Problem Prevention:
Gastrostomy Tube Displacement
• Seen with new tube
placements
• “T” type fasteners used to
maintain stomach
placement to abdominal
wall
• Imperative to recognize
prior to using the tube
Insert picture here
Hexamer, ref #11
Problem Prevention:
Tube Insertions Site:
Drainage/ Infection
McClave, ref #24
Medication Administration:
Maximize Efficacy of Meds, Minimize Risk of Occlusions
• Do not add medications to the formula
• Use liquid medications
• Grind simple compressed tablets to
powder; mix with sterile water
• Open gelatin capsules; mix with sterile
water
• Dilute thick or syrupy medications
• Collaborate with pharmacist
Clogging of Tube
•
•
Prevention
Flush tubes
–
–
•
immediately after stopping feeding
before and after each medication
Do not mix meds
Monitoring for Tolerance
• Tolerance may be subjective
• Gastric residual volume (GRV) has been
traditional measure of tolerance
• Assess for abdominal distention, firmness,
signs of patient discomfort
Monitor for Tolerance of EN
• Gastric Residual Volume (GRV)
– Measure GRV
• Protocols vary across institutions
– GRVs 200-500mL
• Implement measures to reduce risk for aspiration
– Critical Care Guidelines: “Don’t withhold
feedings for GRV <500 mL in absence of
other signs of intolerance”(2)
Monitoring for Efficacy of EN
• Is patient receiving volume prescribed?
• Physical signs:
– weight stabilization or gain
– wound healing
– improved energy and somatic protein status
• Visceral protein status
Monitoring for Adverse Effects
• May include fluid and/or electrolyte
imbalance
– Dehydration
– Fluid overload
– Periodic assessment of electrolytes
• Hyperglycemia
Monitoring for Adverse Effects:
Refeeding Syndrome
• Potentially fatal drop in serum electrolytes
and possible cardiac, neuromuscular and
other sequelae that may occur when
feeding the previously poorly nourished
person1,2,19,20,27
Monitoring for Adverse Effects:
Refeeding Syndrome cont.
• Can be life threatening
• Confusion, coma, convulsions and death can
occur
• Watch for and treat appropriately
– Start slowly, avoid overfeeding
Diarrhea
Loose stools occur in 2-63% of tube fed patients,
depending on definition
• Assess for reasons other than ETF
– Osmotic diarrhea
• hypertonic medications
• high formula osmolality
– Infectious
• excessive microbial growth
• Clostridium difficile or other infection (more virulent strain
may not be detectable by conventional methods)
– Effect of Meds
• antibiotics
• others
Diarrhea Treatment
• Bulk stool
– Fiber may help bulk stool
– Pectin
•
•
•
•
•
Use caution with antiperistaltic agents
Probiotics may be useful
No need to withhold feeding
Monitor fluid and electrolyte status
Consider changing enteral formula
Constipation
• Causes: decreased bowel motility,
inactivity, decreased enteral fluid intake or
lack of dietary fiber
• Symptoms: abdominal distention, high
residuals and impaction
• Use fiber-containing formulas and provide
adequate fluid
• Stool softeners, stimulants or general
bowel routine may be useful
Assessment of Stool
Psychosocial issues
• Food and mealtimes have social
significance
• Person who can no longer eat/drink may
mourn food.
• The Oley Foundation can be a resource
for patients (http://www.oley.org)
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Adkins, SM. Recognizing and preventing refeeding syndrome. DCCN - Dimensions of Critical Care Nursing. 2009; 28(2):
53-8; quiz 59-60.
Bankhead R, Boullata J, Brantley S et al and the ASPEN Board of Directors. Enteral nutrition practice recommendations.
JPEN: Journal of Parenteral & Enteral Nutrition. 2009; 33(2): 122-67.
Cortrak Med Systems, Viasys Medical Systems.
Edes, T. E., Walk, B. E. et al. Diarrhea in tube-fed patients: Feeding formula not necessarily the cause. The American
Journal of Medicine. 1990; 88(2): 91-93.
Elasser TH, Klasing KC et al. The metabolic consequences of stress: Targets for stress and priorities of nutrient use. The
Biology of Animal Stress: Basic Principles and Implications for Animal Welfare. G. P. Moberg and J. A. Mench. 2000;
New York, CABI Publishing.
Garcia R, Jendresky L, Colbert L, Bailey A, Zaman M, Majumder M. Reducing ventilator-associated pneumonia through
advanced oral-dental care: A 48 month study. American Journal of Critical Care. 2009; 18(6): 523-32.
Guenter, P., & Silkroski, M. Tube feeding: practical guidelines and nursing protocols, 2001; ASPEN Publishers, Inc.
Hadfield R, Sinclair D et al. Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill. Am J
Respir Crit Care Med. 1995;152: 1545-1548.
Halm MA, Armola R. Effect of oral care on bacterial colonization and ventilator-associated pneumonia. American Journal
of Critical Care. 2009;18(3): 275-278.
Hanneman SK, Gusick GM. Frequency of oral care and positioning of patients in critical care: A replication study.
American Journal of Critical Care. 2005;14(5): 378-386.
Hexamer, B. Pressure necrosis: Implications and interventions for PEG tubes. NCP. 1997; 12(6), 256-258.
Howell MD, Novack V, Grgurich P, Soulliard D, Novack L, Pencina M, Talmor D. Iatrogenic gastric acid suppression and
the risk of nosocomial Clostidium difficile infection. Archives of Internal Medicine, 2010;170(9), 784-790.
Makk L, McClave SA et al.. Clinical application of the metabolic cart to the delivery of total parenteral nutrition. Critical
Care Medicine. 1990; 18(12):1320-7.
Martin CM, Doig GS et al. (2004). Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and
parenteral therapy (ACCEPT).[see comment]. CMAJ Canadian Medical Association Journal. 2004; 170(2):197-204.
References, cont
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
McClave SA, Dryden GW et al. (2002). Issues of nutritional support for the patient with acute pancreatitis.
Seminars in Gastrointestinal Disease. 2002;13(3): 154-60.
McClave SA, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult
critically ill patient. JPEN J Parenter Enteral Nutr. 2009; 33(3): 277-316.
McClave SA, et al., Poor validity of residual volumes as a marker for risk of aspiration in critically ill
patients.[comment]. Critical Care Medicine. 2005; 33(2): 324-30.
McClave SA, Greene LM et al. Comparison of the safety of early enteral vs parenteral nutrition in mild acute
pancreatitis. JPEN: Journal of Parenteral & Enteral Nutrition. 1997; 21(1):14-20.
McClave SA, Short, AF et al. Total parenteral nutrition: Conquering the complexities. Postgraduate Medicine
1990; 88(1): 235-9.
McClave SA, Snider H et al. Clinical nutrition in pancreatitis. Digestive Diseases & Sciences. 1997; 42(10):
2035-44.
McClave SA, Spain DA et al. Nutritional management in acute and chronic pancreatitis. Gastroenterology
Clinics of North America. 1998; 27(2): 421-34.
McClave SA. Nutrition support in acute pancreatitis. Gastroenterology Clinics of North America. 2007; 36(1):
65-74.
McClave, SA. Nutritional support in acute pancreatitis. Nestle Nutrition Workshop Series Clinical &
Performance Program. 2003; 8: 207-15; discussion 215-21.
McClave,SA. Care and Long-Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes. JPEN.
2006; 30(1), S27-S38.
McClave,SA. Care and Long-Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes. JPEN.
2006; 30(1), S27-S38. (pictures)
Nestle and A.S.P.E.N. Be ALERT and Be AWARE posters. A.S.P.E.N. website
safety page. www.nutritioncare.org/safety. Accessed June 7, 2010.
References, cont
27. Orr P, Case K et al. Metabolic response and parenteral nutrition in trauma, sepsis, and burns. Journal of Infusion
Nursing. 2002; 25(1):45-53.
28. Panteli JV, Crook MA. Refeeding syndrome still needs to be recognized and managed appropriately.[comment].
Nutrition. 2009; 25(2): 130-1.
29. Patel U, Sriram K et al. Acute respiratory failure due to refeeding syndrome and hypophosphatemia induced by
hypocaloric enteral nutrition.[see comment]. Nutrition. 2009; 25(3): 364-7.
30. Pinilla JC, et al. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a
prospective, randomized controlled trial. J Am Geriatr Soc. 2001; 25: 81-86.
31. Schleder B, Stott K, Lloyd RC. The effect of a comprehensive oral care protocol on patients at risk for ventilatorassociated pneumonia. Journal of Advocate health Care. 2002; 4(1): 27-30.
32. Seres D, Compher C. et al. 2005 American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards
and Guidelines survey." Nutrition in Clinical Practice. 2006; 21(5): 529-32.
33. Shepherd A. Nutrition support 2: exploring different methods of administration. Nursing Times. 2009; 105(5): 14-6.
34. Taylor S, et al. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition
on clinical outcome in mechanically ventilated patients suffering head injury. Critical Care Medicine.1999; 27: 2525
- 2531.
35. Thorell A, Nygren, et al. Insulin resistance: a marker of surgical stress. Current Opinion in Clinical Nutrition &
Metabolic Care. 1999; 2(1): 69-78.
36. Trabal J, Leyes P et al. Factors associated with nosocomial diarrhea in patients with enteral tube feeding.
Nutricion Hospitalaria. 2008; 23(5): 500-4.
37. Tresley J,,Sheean PM, et al. Refeeding syndrome: recognition is the key to prevention and management. Journal
of the American Dietetic Association. 2008; 108 (12):2105-8.
38. University of Michigan Hospitals and Health Centers; Patient Food and Nutrition Services
39. Vacek, Jana. Gastrostomy image. Sanford USD Medical Center. 2010; Sioux Falls, SD.