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66 Cards in this Set
- Front
- Back
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purpose of enteral nutrition
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Provides nutrition and hydration when patients cannot eat
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feeding tubes also used for...(2)
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◦Medication Administration
◦Suction- hooking tube to pump and suction GI |
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3 problems with feeding tubes
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Clogging- viscous solutions, meds...
Diarrhea- esp when initiating with too much osmotic load Pulled out- psych pt |
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6 types of feeding tubes
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nasoenteric (NE)-
needle catheter jejunostomy (NCJ) Nasogastric (NG) Orogastric (OG) jejunostomy (J) Gastric (PEG) |
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nasoenteric tube properties (size of bore, property of the tube, type of meds, short or long term use? ease of placement)
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◦Flexible
◦Small bore ◦Use liquid meds only short term use can be placed bedside |
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needle catheter jejunostomy (NCJ) - medication form administered, size of bore, how inserted
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liquid form for meds due to clogging
◦Small bore ◦Inserted surgically |
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Nasogastric (NG) Orogastric (OG)- size of bore, placement of tube, how to admin medicine
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◦Large bore
◦Can be placed at bedside (used a lot in hospitals) ◦Can administer crushed tablets or opened capsules with flushing of tube with water |
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Gastric (PEG or G) or jejunostomy (J)- how is it placed (4)
size of bore administration of meds long or short term? |
◦Placed by laparoscopic or open surgical techniques, endoscopy, or fluoroscopy (imaging technique that uses X-rays to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope)
◦Large bore (G larger than J) ◦Can administer crushed tablets or opened capsules with flushing of tube with water more long term placement (go into stomach or jejunum rather than through nose) |
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PEG vs NG tube- which is more common?
why (2) |
A percutaneous endoscopic gastrostomy (PEG) tube more common than NG Tube
◦PEG is More comfortable for the patient and less likely to cause aspiration (into lungs) |
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why might we use tubes? (3)
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◦Poor appetite
◦Hyper-metabolism ◦Neurological disease/injury |
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if person has in tact GI tract , enteral or PN?
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enteral
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why enteral (over parenteral)? (7)
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Gastric protection
Mucosal integrity Glucose control easier than parenteral Enhanced immune function?? because GI tract has lymphoid tissue, if it is being unused we lose some of that immune fxn Less expensive than parenteral Safer than parenteral More physiologic |
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When the GI tract is unused what happens to its immunologic fxns
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the immunologic functions are inhibited
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largest immune organ in the body
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GI- also protects other body systems
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bacterial translocation (2)
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Bacteria and toxins enter abdominal cavity through GI wall
can occur often if GI tract unused |
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gastric placement of tube benefits (3) vs. past...gastric placement
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◦Decrease in stress ulcers
◦Less diarrhea (stomach designed to take higher osmotic load) ◦Physiologic |
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when would you want to place the tube past the stomach? (2)
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◦Less aspiration (e.g. if hiatal hernia and food keeps getting pushed up into lungs)
◦Bypass gastric ileus |
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different caloric densities in formulas- standard vs. moderate to low volume vs. elemental (in kcal/mL)
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Standard formulas contain from 1-1.2 kcal/mL
Moderate to low volume formulas contain 1.5-2 kcal/mL Elemental 1kcal/mL |
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special formulas marketed for these special conditions (4) evidence of improved outcomes?
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◦Renal
◦Hepatic ◦Diabetes ◦Pulmonary no |
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how to start out enteral nutrition- when to start? then how to feed/time period (3)
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Feed early!- Do not delay start of feedings (like as soon as you determine they won't be eating for at least a couple days)
Initiate feedings at about 25% of calculated daily goal (less than daily goal to avoid stuff like refeeding syndrome and to be gentle to gut) Advance over 48-72 hrs Elevate head of bed 30 degrees to avoid aspiration |
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methods of feeding delivery (4)
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Continuous gravity
Intermittent gravity Bolus- syringes Pump- Cycling 12 hr on 12 hr off |
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5 complications of enteral feeding
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Aspiration-
GI distension- can be signs of aspiration Vomiting- can be sign of aspiration Diarrhea/Constipation Dehydration- not enough water? |
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how to monitor for aspiration
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check gastric residual volume???- rec'd at various intervals- wtf. if super high probably higher risk
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dehydration with enteral feeding- how to avoid
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◦Free water flushes- enteral solutions are viscous so flush with water (supplementation of fluids)
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what kind of water to use for free water flushes- tap vs. sterile
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◦Tap vs. sterile- ASPEN recs sterile for meds, otherwise tap is ok for just flushing if pt is healthy
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monitoring for efficacy- what to look at (4)
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Pre-albumin
Weight Electrolytes Hydration status |
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poor practice in med admin in enteral feeding can lead to...(4)
key to prevent these negative outcomes! |
◦tube obstruction
◦reduced drug efficacy ◦increased drug toxicity (dose dumping if crushing modified release) ◦Death! pharm-nurse communication |
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medication mgmt plan- questions to ask regarding medications before deciding to administer via tube (4)
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◦Can medication be temporarily discontinued if tube placement is temp?
◦Can we use an alternative route? topical..rectal.. ◦Can we switch to an alternative medication with similar effects? ◦How much holding of enteral feeding is tolerable? can we hold it while we give meds? |
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medication via tubes- what must you do that a lot of ppl don't do! (4)
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must dilute liquid meds as needed
must flush tubes before or b/t meds must admin drugs separately (no mixing in syringe) avoid crushing modified release dosage form |
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8 considerations to look at when deciding how to admin meds
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Type of tube- size of bore, is bore large enough that we can crush tabs or do we have to use solution
Location of the tube in the GI tract- can affect drug absorption (e.g. sucralfate has to be used in stomach) Length of patient’s GI tract- absorption issues, first pass effect Effects of food on the medication- empty stomach (esp if continuous feeding) Is liquid form available or compoundable? Properties of dosage form- oily, cloggy? Stability of medication- acid labile via g-tube is bad Drug/nutrient interactions |
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issue with chem/physical instabilities in med admin with tubes- possible when?
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Chemical and physical incompatibilities possible from mixing powdered (crushed) meds as well as liquids- don’t to it
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commercially available drugs are intended for what?
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Commercially available drugs that are intended for systemic effect via oral administration are designed with the physiology of the healthy, intact GI tract in mind!
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medications- can they be added directly to nutrition formulations?
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Medications should not be added directly to the nutrition formulations.
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dosage forms and feeding tubes (2)
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Use liquid dosage forms is possible
NOTE which tablets cannot be crushed |
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If crushable tablets are used,how do we admin
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the tablet should be crushed into a fine powder and mixed with 10 to 15 mL of purified water
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If capsules can be opened, how to admin
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open and mix powder/granules with 10 to 15 mL of water
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ASPEN guidelines for flushing (how much water, when)
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Flush tube with 15 mL of water before medication administration, between individual meds and after administration of medications
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Medication should be placed in a
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needleless syringe
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documentation of water used...in...tubes
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Document total amount of water on I&O sheet
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medications - how to deliver (2)
how not to deliver |
Medication should be allowed to flow in by gravity.
Gentle boosts (approximately 1 inch down) should be given with the plunger if the medication does not flow. Medications should not be pushed through the tubes |
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do not use what formulations for tubes (2)
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Sustained Release and Enteric coated
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Pellets in some microencapsulated products- ok?
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Pellets in some microencapsulated products may be OK
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Soft gelatin capsules- how to admin
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stick needle in and pull out
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some issues with liquid meds in tubes (4)
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◦may be for peds- so have to use large volumes- this can results in high osmolality-diarrhea
◦Not always bioequivalent to solid dosage form ◦Inactive ingredients may cause problems- e.g. Sorbitol for sweet- if given in large volumes = laxative efffect ◦Syrups or other acidic drugs- clogging? |
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very high osmotic load meds to admin via tubes (4) (diarrhea medS)
how to stop diarrhea |
APAP
cimetidine docusate lactulose dilute with water |
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5 drugs that cause issues
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Proton pump inhibitors
Laxatives Phenytoin Warfarin Fluoroquinolones |
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what's zegerid?
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omeprazole/sodium bicarbonate
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a lot of PPIs are...? why does this cause issues
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acid labile, so they will be delayed release and enteric coated dosage forms->don't give or special conditions like using bicarb or acidic juices
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PPI granules- crush?
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Do not crush granules (in capsules)- juts let dissolve
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gastric vs. jejunum admin of PPIs- how to compound
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◦Gastric-Mix with acidic juices so it doesn't dissolve the coating
◦Intestinal-Mix with Sodium Bicarbonate 8.4% to dissolve delayed release coating? |
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omeprazole: how to prep for administration via NG or G-tube- use what form
directions for compounding (4) |
Use packets for oral suspension
Add 5 mL of water to the contents of a 2.5 mg packet (or 15 mL of water for the 10 mg packet) Immediately shake the syringe and leave 2 to 3 minutes to thicken Shake the syringe and inject through the NG or G-tube Refill the syringe with an equal amount of water and shake and flush any remaining contents |
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esomeprazole available forms for compounding- mix with what?
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Available as delayed release oral capsules and packets to make an oral suspension
mix with water (15 mL for packet, 50 for caps) |
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esomeprazole caps can only be used for which tube
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NG??
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lansoprazole- which tube? 2 forms and what to mix in
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NG tube
capsules- open and mix in apple juice Orally disintegrating tablets- place in syringe with water |
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pantoprazole- 2 forms- use which one?
mix with what? |
Available as delayed release tablets and packets (granules for suspension)- mix with apple juice
DO NOT USE TABLETS- use packets |
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zegerid- avail in what form- mix with what
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Available in packets for suspension- mix with water
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PPI with no manufacturer rec for tube admin (2)
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dexlansoprazole
rabeprazole (only has delayed release) |
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issue with bulk forming laxative
how to remedy |
clogs waiting to happen
change to higher fiber formulas like jevity if they need a laxative |
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warfarin issue with tubes
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decreased effect
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fluoroquinolones with tubes- main issues (2)
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◦Erratic pharmacokinetics when given via tube
◦Binding to divalent cations |
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do not use which fluoroquinolone for tube?
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◦Do not use Cipro Suspension via tube- oily and thick- clogs
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adjusting meds for feeding tubes- after you stop feeding what must you do?
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re-adjust meds- e.g. warfarin have to decrease dose
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phenytoin issue
options for admin (2) |
Dramatic decrease in absorbance via tube vs. oral- increase dose on tubes, decrease when you come off
◦Hold feeding for couple hours before and after admin- kind of difficult if you have large volume feedings and if TID ◦Dose by blood level/response- increase dose til we get blood level/response- but must readjust dose after feeding |
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Medications cause occlusion in approximately ___% of patients
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15%
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2 options if med clog
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flush away
replace tube |
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3 things to use to flush tubes with clogs
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Carbonated water
Clog Zapper- enzymes that digests proteins in clogs- not that helpful for drug clogs Alkalinized enzyme solution-changing pH (like bicarb) and this can get rid of some drug clogs |
