…Nurses’ Role…

L.Mageswary Dietitian

Hospital Selayang

14 -15 Aug ASMIC 2015

Doctor

Dietitian

Pharmacist

Nurse Physiotherapist

Occupational therapist

Patient

Patient Centered Care • Patients’ needs & preferences • Good communication between healthcare professionals & patients • To promote & provide education • To develop common protocols and guidelines

Discussion Today…

• Safe EN Orders

• EN Label

• Storage & Administration

• Safe EN Preparation

• Selection and Maintenance of Enteral Access

• EN Complication & Management

Nutrition Screening & Assessment

• Patient Risk for Malnutrition

• Any critically – ill patient who is anticipated to remain unable to take oral nutrition for ≥ 5 days with significant comorbid disease.

• Any patient who has or had oral intake that is inadequate to meet current nutritional needs. (i.e < 50% of estimated required calories for > 5 days)

Weight Height Knee

height Intake/ Output

Appetite

Ability to

swallow and eat

Formula Orders

Orders of EN should be written completely and specifically for each patient:

• Pt demographics (Name, Age, MRN and Bed No.)

• Formula trade name

• Enteral route (gastric or postpyloric) and access (nasogastric NG or nasoduodenal)

• Administration method (pump-assisted or bolus)

• Rate of administration

Label: EN formula administration

• Pt name

• Formula type

• Enteral access

• Administration method

• Name/ initial of those preparing & hanging products

• Date & time of formula preparation and hung

• Expiration date & time

• Not for I.V Use

All feeding bottles, bags

and syringes in feeding pumps

should have label

Always confirm that the correct formula is being given to the patient by comparing the label to the order.

Storage and administration

Check date of expiry

Store unopened formula in a designated dark, dry, cool place, according to institutional protocol and

manufacturer recommendations

Reconstituted formula that’s not used should be immediately refrigerated and discarded within 24 hours

Liquid EN formulas should be used in preference to powdered

• reconstituted formulas has higher risk of contamination

• Blenderised Diet NOT RECOMMENDED

Enteral administration set with a drip chamber is preferable to one with no drip chamber to prevent retrograde bacterial contamination

of the formula during administration.

Preparation of EN

EN formulas be prepared in a clean environment by specially trained personnel using sterile technique.

wearing a disposable mask, gown, gloves, and head cover may reduce the spread of airborne bacteria.

Hand hygiene

• before preparing and administering EN

• When accessing the enteral tube hub, clean each tubing connection with an alcohol swab.

• Between glove changes and when moving from a dirty procedure, such as gastric residual aspiration, to a clean procedure, such as handling the EN formula

Don’t let any part of the delivery system come into contact with non-disinfected hands, skin, clothing, or other surfaces.

Water

• Type of water in EN – Purified Water

• sterile, solute-free, non pyrogenic water • used for preparing or reconstituting commercial products, • rinsing equipment and utensils • required to produce steril water for irrigation and sterile

water for injection.

– Distilled Water • water that has been vaporized and recondensed but is not

necessarily free of dis-solved or suspended matter; therefore should not be used for the preparation or administration of medications.

– Tap Water • municipal or locally-available potable water that meets the

Drinking Water regulations and is consistent with World Health Organization (WHO) guidelines for water safety.

Selection & Maintenance of Enteral access

Type of enteral access is depending on

• Patient’s disease state

• GI anatomy

• GI function

• Estimated length of therapy

• Capacity of patient or caregiver

Devices inserted via the nose or mouth are intended for short-term use, usually no longer than 6 weeks.

An X-ray is the gold standard for confirming the correct position

Bedside checks for placement can be done by testing the pH of the aspirate.

• Fluid from the stomach is typically clear and colorless or grassy green and has a pH of 5 or less

• However, gastric aspirate may not be reliable if a patient is taking a medication to suppress gastric acid, such as famotidine or pantoprazole

• If the tube could possibly have migrated into the lungs, fluid looks pale yellow and has a pH of 7 or higher

The auscultatory method isn’t reliable.

1

2

3

4

5

Selection & Maintenance of Enteral access

• Percutaneous endoscopic gastrostomy (PEG),

• percutaneous endoscopic jejunostomy, and

• Percutaneous endoscopic gastrojejunostomy

Long term feeding devices (> 4 weeks)

• DO NOT USE Urinary drainage catheters or GI drainage – they don’t have external anchoring devices and can migrate, causing

obstruction or aspiration

• Feedings Initiation: within 2 hours of the placement of a PEG tube in adult. – without waiting for flatus or a bowel movement.

EN Formula Hang Time

ASPEN Enteral Nutrition Practice Recommendations 2009

Hang time is defined as the time an EN formula is considered safe for delivery to the patient, beginning from the time when the formula was reconstituted, warmed, or decanted, or from the time when the original package seal was broken.

Administration sets for open systems should be changed at least every 24 hours

Tube Occlusion

• Poor flushing technique

• Interaction between multiple medications and protein-rich formula

• Inappropriate administration of medication

• Mixing of tube feeding formula with gastric fluid during gastric residual

checks

• small-diameter tubes

Loosening and rotating a gastrostomy tube may prevent blockage through mucosal overgrowth and may reduce peristomal infections (grade C).

Do

• Use liquid form drugs when available

• Dilute thick liquid medications to

reduce osmolality

• Consider timing of medication –

empty or full stomach

– Phenytoin

– Warfarin

– Antibiotics (Tetracyclines, Quinolone)

• Flush feeding tube with 15 – 30 ml

water frequently

– Before and after checking residuals

– Before and after feeding

– between medication doses

– Every 4 hourly if continuous feeding

• Choose feeding tube with

appropriate size

Do not

• Use acidic flush fluids

Cranberry juice, carbonated

cola

Water is the best flush fluid

Tube Occlusion

use sterile water in immuno-compromised or critically ill

& Post-pyloric feeding

Enteral Tube Misconnections • Multiple medical committees have convened since 1972 to address

the safety requirements for enteral feeding set connectors and adaptors.

– Color-coding and/or labeling should always be used (doesn’t entirely eliminate the risk)

– Be knowledgeable about • the use of the devices,

• trace all lines back to their origin, and

• ensure that they’re secure.

– Use only oral syringes, not luer-lock syringes, labeled “for oral use only,” to draw up and administer medications into the feeding tube

Golden Standard: Develop and use enteral equipment that is designed to be completely incompatible with all existing I.V. connections

GRV AND ASPIRATION RISK

When should I get worried ?

Gastric Residual Volumes:

Controversial?

• ADA Guidelines 2008 > 250 cc

• Canadian C.P.G. > 250 cc

• ESPEN Guidelines 2006 not addressed

• ASPEN / SCCM > 500 cc

• New Canadian CPG Guidelines late 2009 over

400 cc

Jaime C.P et al. JPEN 2001

Purpose: To compare gastrointestinal tolerance to two EN protocols in critically ill patients in

medical/surgical/trauma ICU.

Method: 1. Prospective RCT, 96 consecutive pts expected to stay in ICU ≥ 3 days on EN. 2. Group I: GRV 150 ml w optional prokinetic. Group II: GRV < 250 ml w mandatory prokinetic 3. GI tolerance (high GRV, emesis and diarrhea) time to reach the goal rate of feeding and the percentage of nutritional requirements received and was recorded.

Results: 1. Group I: 19 of 36 patients (53%) had one or more episodes of high GRV (p < .005) 2. Group 1: reached their goal rates on average in 22 hours and received 70 % of nutritional requirements

Results: 1. Group II: 10 of 44 patients (23%) had one or more episodes of high GRV (p < .005) 2. Group II: reached their goal rates on average in 15 hours and received 76% of nutritional requirements

No significant difference between emesis, diarrhea total episodes of intolerance.

Jaime C.P et al. JPEN 2001

Conclusion: The incidence of EN intolerance was reduced by using a GRV of 250 mL along

with the mandatory use of prokinetics.

The study showed a trend of improved enteral nutrition provision and reduced the time to reach the goal rate in group II.

These improvements support the adoption of the proposed feeding protocol

for critically ill patients.

Severity Definition Treatment

Mild < 200 ml Return GRV

Continue EN protocol

Moderate 200 to 500 ml 1st episode, continue EN protocol

2nd episode, start prokinetic agent

3rd episode, reduce EN rate by half

4th episode,

Stop Gastric feeding

Place NJ tube

Start EN protocol

Severe > 500 ml Stop gastric feeding

Place NJ tube

Start EN protocol

Marr AR et. Al. Gastric Feeding as an Extension of an Established Enteral Nutrition protocol.

Nut in Clinical Practice Oct 2004

GRV Levels

Recommendation: To reintroduce gastric content to improve GRV management without

increasing the risk for potential complications

Recommendation Evidence

Level

EN patients should be assessed for aspiration risk E

Elevate head of the bed 30 - 45º in all patients C

Switch to continuous infusion if intolerant D

Initiate agents to promote motility where feasible Prokinetic drugs (metoclopramide and erythromycin) Narcotic antagonists (naloxone and alvimopan)

C

Divert level of feeding by post-pyloric placement C

Use of chlorhexidine mouthwash twice daily to reduce risk of ventilator-associated pneumonia.

C

Reduce Risk of Aspiration

Both gastric enteral feeding and feeding in supine position vs. semi recumbent position, are

independent risk factors for nosocomial pneumonia in ventilated patients

Drakulovic MB, 1999. Lancet 354:1851–58

Prop-up patient at 30 – 45 ° during and after feeding

Head Up Position

To minimise aspiration, patients should be fed propped up by 30° or more and should be kept propped up for 30 minutes after feeding.

Continuous feed should not be given overnight in patients who are

at risk (grade C).

Small bowel fed patients have improved energy delivery in

some studies

Improved tolerance of enteral nutrition and concomitant faster achievement of desired calories

Kortbeek JB J. Trauma 46:992–96

Long term rehabilitation patients should transit to gastric feeding

AM Cook et al. Nutrition Consideration in Traumatic Brain Injury, NCP Dec 2008

Postpyloric tube suggested for high-risk patients in ICU • High gastric residual volume

• Sedation

• Supine position Canadian Clinical Practice Guidelines, JPEN 2003

Small Bowel Feeding

• Quantify stool volume – Is it really diarrhea?

• Review medication list – Switch from IV to enteral route

– Antibiotic prescription

– Sodium and potassium phosphate

– Lactulose

• Check for C. difficile or other infectious causes

• Check hypoalbuminemia

• Try fiber (soluble fiber)

• Check feeding method

• Anti-diarrheal agents once infectious causes are rule out

• Continue to feed

Not Always the Formula

Diarrhea

Is Diarrhea present

Continue same feeding

Change medication

Continue feeding

Check stool for C.difficile toxin

Continue feeding

Advance to goal rate

Continue same feeding

Decrease rate until tolerance

achieved

Consider fibre supplement

If hypoalbuminaemia, consider

semi or elemental formula

* Is stool clinically significant?

Are medications the

possible

Cause?

Is patient receiving

antibiotic/

Laxatives?

Is diarrhea resolved?

YES

YES

YES

YES

YES

NO

NO

NO

NO

• Liquid stool > 300 ml/day *

• 4 loose stools/day

• Risk of contamination of wound or catheters

Metabolic Complications Complication Possible Cause Possible Treatment

Hyponatremia Excessive free water, abnormal sodium loss

Change to Fluid restricted formula, discontinue water boluses/IVF, replace sodium losses

Hypernatremia Inadequate hydration, increased fluid losses, Diabetes Insipidus

Add or increase water boluses or IVF

Hypokalemia Anabolism/ refeeding, diuretics/medications

Supplement potassium

Hyperkalemia Renal Failure, metabolic acidosis, catabolism, GI bleed, Acute dehydration

Correct imbalance, Change to renal formula as appropriate

Hypophosphatemia

Anabolism/ refeeding

Supplement phosphorus

Hyperphosphatemia

Renal failure

Change to renal formula, phosphate binders if necessary

Hypomagnesemia Anabolism/ refeeding, diuretics/medications

Supplement magnesium

Hyperglycemia Diabetes, steroid therapy, Sepsis, Trauma, Pancreatitis

Insulin drip per protocol. Goal is to maintain blood glucose at or less than 110 mg/dL (6.1 mmol/l)

Highlights of the protocol

Volume of feeds

Feeding progression

Acceptable gastric

aspirates

Use of prokinetic

Use of small bowel

feeding

When to consider TPN

Management of

Complications

Evidence-Based Feeding Protocol

Intermittent Feeding Bolus Feeding

At all ward

Hospital Selayang

Storage Preparation

Delivery Cleanliness of utensil

Stay current to keep patient safe

1. Practice hand hygiene and sterile technique

2. Proper patient positioning 3. Appropriate medication administration

technique 4. Good & Safe Nutrition Support Practices 5. Detailed documentation

Continuous Nurses Education in GICU

Feeding Pump Training

Kursus Nutrition Support for Nurses

…Safe Delivery of Nutrition Support Involves Multidisciplinary Approach…

THE MOST IMPORTANT MEMBER ARE

***NURSES***