GCC Nurse — Enteral & Parenteral Nutrition Guide

⚡ Enteral Feed Rate Calculator

Patient Weight (kg)

Target Energy (kcal/kg/day)

Formula Energy Density

Feeding Route

Target Volume / Day

Target Rate

Starter Rate (Day 1)

Step-up Rate

Target Protein (1.2–1.5 g/kg/day)

📅 Energy Requirements

Clinical Situation	Energy (kcal/kg/day)	Notes
Standard adult (well-nourished)	25–30	Use actual body weight
Critical illness — acute phase (Days 1–7)	20–25	Avoid over-feeding; indirect calorimetry ideal
Critical illness — recovery phase	25–30	Increase as patient stabilises
Obesity (BMI >30)	11–14 kcal/kg actual or 22–25 kcal/kg IBW	Use adjusted body weight (ABW = IBW + 0.25 × (actual − IBW))
Burns	Up to 35–40	Curreri formula often used; reassess frequently
Refeeding syndrome risk	10–15 to start	Increase cautiously over 4–7 days

Harris-Benedict Equation (Basal Metabolic Rate)

        Men: BMR = 66.5 + (13.75 × W kg) + (5.003 × H cm) − (6.755 × Age)

        Women: BMR = 655.1 + (9.563 × W kg) + (1.85 × H cm) − (4.676 × Age)

        TEE = BMR × Activity Factor × Stress Factor

Activity Factor	Stress Factor
Bed rest: 1.2 \| Ambulatory: 1.3–1.5	Minor surgery: 1.1 \| Major surgery: 1.2 \| Sepsis: 1.3–1.6 \| Burns: 1.5–2.0

🧸 Protein Requirements

Clinical Situation	Protein (g/kg/day)	Notes
Healthy adult	0.8–1.0	UK/US reference intake
Standard hospitalised	1.2–1.5	Use actual weight (or ABW if obese)
Critical illness / ICU	1.5–2.0	Higher targets reduce muscle wasting
Burns / major wounds	2.0–2.5	Monitor urea, nitrogen balance
Renal failure (no dialysis)	0.6–0.8	Aim to limit uraemic load
Haemodialysis / CAPD	1.2–1.5	Dialysis removes amino acids
CRRT (continuous renal replacement)	1.5–2.5	Significant amino acid losses in effluent
Hepatic failure (encephalopathy)	0.6–0.8 initially	Do not restrict protein long-term — worsens outcomes
Pressure ulcers / wound healing	1.25–1.5	Plus vitamin C and zinc supplementation

💊 Micronutrient Requirements in Nutrition Support

Key Vitamins

Vitamin	Clinical note
Thiamine (B1)	CRITICAL in refeeding — give IV before feeds start
Vitamin D	Deficiency very common in GCC despite sun exposure; supplement
Vitamin C	Enhanced needs in burns, wounds, critical illness
Vitamin K	Monitor INR in PN patients; enteral feeds contain variable amounts
Folate / B12	Supplement in malnutrition and prolonged PN

Key Minerals & Electrolytes

Element	Key consideration
Phosphate	Monitor daily in refeeding risk; replace IV if <0.5 mmol/L
Potassium	Hypokalaemia common in refeeding and PN; replace cautiously
Magnesium	Hypomagnesaemia impairs phosphate repletion
Zinc	Increased losses in diarrhoea, fistula, burns
Selenium	Supplement in prolonged PN >30 days
Iron	Do not add to PN bag — give separately; monitor in long-term EN

📋 Enteral Feeding Routes — Overview

Route	Duration	Indication	Key Advantage	Key Risk
Nasogastric (NG)	<4 weeks	Short-term enteral access; functional stomach	Bedside insertion; uses gastric digestion	Misplacement into airway; aspiration
Nasojejunal (NJ)	<4 weeks	Gastroparesis; aspiration risk; post-pyloric preferred	Reduced aspiration vs NG; bypasses stomach	Endoscopic/fluoroscopic placement needed; dislodgement
PEG	>4 weeks	Long-term enteral feeding; neurological dysphagia	Avoids nasal trauma; better patient tolerance	Buried bumper syndrome; site infection; granuloma
RIG	>4 weeks	Unable to have endoscopy (e.g. H&N cancer, oesophageal obstruction)	Fluoroscopic — no endoscopy needed	Technically limited centres in GCC
Jejunostomy	Long-term	Gastric outlet obstruction; oesophagectomy; post-pancreatectomy	Post-pyloric; early post-op feeding	Jejunal necrosis if kinked or malpositioned

⚡ NG Tube Insertion & Position Confirmation

NPSA Safety Alert: NEVER administer feeds without confirming NG tube position. Pulmonary misplacement has caused preventable deaths. Confirm BEFORE EVERY feed start and after any vomiting, coughing, position change, or tube dislodgement.

NEX Measurement

        Measure: Nose → Ear lobe → Xiphisternum

        Mark tube at this length. Insert to NEX mark. Adults typically 55–65 cm at nostril.

pH Confirmation Protocol

Aspirate 0.5–1 ml gastric fluid using 50 ml syringe
Apply aspirate to CE-marked pH paper (range 0–6)
pH ≤5.5 = confirmed gastric position — safe to feed
pH >5.5 (or unable to aspirate): do NOT feed — arrange X-ray
Document result in nursing notes

Do NOT use litmus paper (only distinguishes acid/alkali). Do NOT use auscultation ("whoosh test") — this method is unreliable and NOT recommended.

X-ray Confirmation

Required if: pH inconclusive, pH >5.5, patient on PPIs/antacids (raises gastric pH)
Report should confirm: tube tip below diaphragm in the stomach / proximal duodenum
Radiographer or clinician to formally report — nursing staff to receive written confirmation

🗨 Tube Securement & Routine Care

NG Tube Daily Care

Check external length marking every shift
Rotate securement device to alternate nostril daily to prevent pressure injury
Clean nostril with saline-soaked gauze; inspect for ulceration
Flush with 30 ml water before and after each feed/medication
Re-confirm pH before re-starting after any interruption

PEG / Gastrostomy Care

Clean stoma site daily with clean water; pat dry
Check external bumper/disc — should allow 1 cm rotation freely
Rotate tube 360° daily to prevent buried bumper syndrome
Normal: minor serous discharge at stoma for first 4 weeks
Report: purulent discharge, granulation tissue, bleeding, fever
Do not submerge in water for first 2 weeks post-insertion

Buried Bumper Syndrome

Occurs when internal bumper migrates into gastric/abdominal wall. Signs: unable to rotate tube; tube feels fixed; pain on infusion; tube cannot be removed by standard method. Requires urgent surgical review — do not force the tube.

🥊 Formula Selection Guide

Formula Type	Energy Density	Indication	Examples
Standard polymeric	1.0 kcal/ml	Most hospitalised patients with functional GI tract	Fresubin Original, Jevity 1.0
High energy polymeric	1.5–2.0 kcal/ml	Fluid restriction, renal disease, patients needing high kcal in low volume	Fresubin 2 kcal, Ensure Plus
Semi-elemental	1.0–1.3 kcal/ml	Malabsorption, short bowel syndrome, pancreatitis, IBD flare	Peptamen, Survimed OPD
Elemental	1.0 kcal/ml	Severe malabsorption; allergies; enteric fistula	E028 Extra, Vivonex
Renal-specific	1.8–2.0 kcal/ml	CKD not on dialysis — low electrolyte, low phosphate	Nepro, Renilon
Hepatic-specific	1.3 kcal/ml	Encephalopathy — branched-chain amino acid enriched	Heparon Junior, Fresubin Hepa
Diabetic-specific	1.0–1.5 kcal/ml	DM with glycaemic control issues on EN	Glucerna, Diason
Immune-enhancing	1.0–1.3 kcal/ml	Pre-op major surgery, trauma, oncology (arginine/omega-3/glutamine)	Impact, Reconvan
Fibre-enriched	1.0–1.5 kcal/ml	Constipation; normalise bowel function	Jevity 1.5, Fresubin Fibre

In GCC: Fresubin, Ensure, Jevity, and Nutrini halal-certified versions widely available. Confirm halal certification with pharmacy/dietitian.

⌚ Starting Rates & Progression

Continuous Pump Feeding

Day 1: Start 20–30 ml/h
Increase by 10–20 ml/h every 4–6 hours
Target rate typically 60–100 ml/h
Aim to reach full target volume within 24–48 h (unless refeeding risk)
Nurse checks: rate on pump, volume infused, patient comfort

Bolus / Gravity Feeding

200–400 ml per bolus over 20–30 minutes
4–6 boluses per day
Sit patient at 45° during and 1 hour after
Check GRV before each bolus
More physiological — promotes hormone cycling

        Head of Bed: Maintain at least 30–45° during all enteral feeds and for 1 hour after bolus feeds. This is a primary aspiration prevention measure.
      

📈 Gastric Residual Volume (GRV) Management

GRV Finding	Action
<250 ml on continuous feed	Continue feed as prescribed — no action needed
250–500 ml	Reduce feed rate by 50%; consider prokinetic (metoclopramide 10 mg TDS or erythromycin 125–250 mg BD); recheck in 2–4 h; consider post-pyloric feeding
>500 ml	Stop feed; replace aspirate (to avoid electrolyte loss); call medical team; assess aspiration risk; oral care; consider switching to NJ/jejunal access
Retained medication	Check GRV before drug administration — withhold if >250 ml

Note: Routine GRV monitoring is debated. Some guidelines (SCCM/ASPEN 2016) suggest GRV >500 ml threshold, while others no longer recommend routine GRV checks. Follow your local protocol. The key is clinical assessment of tolerance (nausea, vomiting, distension, aspiration signs).

💧 Flush Schedule & Drug Administration

Standard Flush Protocol

30–50 ml sterile water every 4–6 hours during continuous feeding
30 ml before AND after every medication
30 ml before AND after each bolus feed
Use sterile water in immunocompromised / ICU patients
Tap water acceptable in ward patients with intact immune system

Drug Administration via Tube

Always pause feed for drug administration
Flush before first drug, between separate drugs, and after last drug
Use liquid formulations where available
Crush ONLY immediate-release tablets — NEVER crush modified-release, enteric-coated, or cytotoxic drugs
Confirm with pharmacist: phenytoin, warfarin, ciprofloxacin, sucralfate interact with EN

🔤 Enteral Nutrition Complications & Management

Complication	Possible Cause	Nursing Management
Diarrhoea	High osmolality, fast rate, infection (C. diff), antibiotics, medications (e.g. sorbitol)	Reduce rate; check formula; stool C. diff; review medications; consider fibre formula; skin care
Constipation	Opioids, dehydration, immobility, low-fibre formula	Increase water flushes; fibre formula; bowel chart; laxatives per protocol
Nausea/vomiting	Delayed gastric emptying, high GRV, infection, medications	Check GRV; reduce rate; prokinetics; reassess route (NJ)
Aspiration pneumonia	Tube misplacement, supine position, high GRV	Stop feed; suction; confirm tube position; HOB ≥30–45°; chest X-ray; antibiotics if infected
Blocked tube	Insufficient flushing, crushed medications, viscous formula	Warm water + syringe pressure; pancreatic enzyme solution (Creon dissolved in water); do NOT use cola
Hyperglycaemia	High carbohydrate load, stress response, steroids	BGL monitoring; insulin sliding scale; consider diabetic formula; notify team if BGL >10 mmol/L
Fluid overload	High-volume standard formula in cardiac/renal patients	Switch to high-energy, low-volume formula; strict fluid balance; daily weights

💋 Indications for Parenteral Nutrition

Always prefer the enteral route if the gut is accessible and functional — "If the gut works, use it."

PN Indicated When:

Gut inaccessible or non-functional
Short bowel syndrome (insufficient absorptive capacity)
Prolonged ileus (>5–7 days with no expected resolution)
Bowel obstruction (mechanical, not amenable to surgery/stenting)
High-output enteric fistula (>500 ml/day) — EN may be tried first
Severe mucositis / GI GVHD (bone marrow transplant)
Bowel ischaemia; mesenteric thrombosis
Severe acute pancreatitis where NJ feeding is not tolerated (rare)

PN Not Recommended:

Functional GI tract available
Expected duration <5–7 days in well-nourished patient
Haemodynamic instability (resuscitate first)

🔌 Central vs Peripheral PN

Central PN (CPN)

Via CVC, PICC, or tunnelled line (Hickman)
Osmolality: unlimited (typically 1200–1800 mOsm/L)
Full nutritional requirements met
Duration: preferred for >2 weeks
CLABSI risk — strict aseptic technique
Dedicated lumen for PN only

Preferred route for standard PN

Peripheral PN (PPN)

Via peripheral cannula or midline catheter
Osmolality <900 mOsm/L to avoid thrombophlebitis
Limited: lower glucose + amino acid concentrations
Duration: max 7–14 days
Risk: thrombophlebitis — change cannula site every 48–72 h
Useful: bridge to central access; short-term supplemental PN

Short-term / supplemental only

💊 All-in-One (AIO) PN Bags

        AIO bags contain all macronutrients + electrolytes + vitamins + trace elements compounded in pharmacy under strict aseptic conditions. Check the label carefully before hanging.
      

Label Check — Before Hanging ANY PN Bag:

Patient name, DOB, ward, and prescriber — must match patient
Date and time of preparation; expiry time (usually 24–30 h from compounding)
Glucose % (e.g. 20%); amino acid g (e.g. 57 g); lipid g (e.g. 50 g)
Electrolytes: Na, K, Ca, Mg, phosphate, acetate (check against recent bloods)
Volume (ml) and rate (ml/h)
Vitamins and trace elements added
Inspect bag: discard if turbid, phase-separated (white + yellow layers separated), precipitate visible, or leak detected

⚙ PN Administration — Nursing Practice

Line Management

Dedicated lumen — no other IV drugs or fluids through PN lumen
Exceptions: only Y-site compatible drugs validated by pharmacy (rare)
In-line filter: 1.2 micron for lipid-containing AIO bags; 0.22 micron for lipid-free solutions
Change giving set every 24 hours with bag change
Change bag every 24 hours (do not allow to run through or hang extra time)
NEVER interrupt PN to administer blood or colloids

Aseptic Technique at Line

Hand hygiene + non-sterile gloves before handling line
Clean hub with 2% chlorhexidine/70% alcohol — 15 seconds scrub, 30 seconds dry
Use needleless closed connectors
Change dressing per CVC protocol (typically every 7 days if intact chlorhexidine-impregnated dressing)
Daily inspection of insertion site: redness, swelling, discharge, tracking
Unexplained fever/rigors: blood cultures from line AND peripherally before antibiotics

⚠ PN Complications

Category	Complication	Signs	Management
Mechanical	Catheter occlusion	Unable to aspirate/infuse; pump alarm	Urokinase/alteplase instillation; do not force; CXR if needed
	Air embolism	Hypoxia, cyanosis, "mill-wheel" murmur, haemodynamic collapse	Left lateral decubitus; Trendelenburg; O2; emergency call; aspiration via central line
	Pneumothorax	Post-insertion breathlessness, reduced breath sounds	CXR immediately post-insertion; chest drain if tension
Metabolic	Hyperglycaemia	BGL >10 mmol/L; polyuria; confusion	Insulin infusion protocol; may need to reduce dextrose in PN bag; BGL every 4–6 h
	Hypoglycaemia	BGL <4 mmol/L on sudden PN interruption	NEVER abruptly stop PN — taper rate over 1 h; or hang 10% glucose if PN stops unexpectedly
	Hyperlipidaemia	Lipaemic plasma; triglycerides >4.5 mmol/L	Reduce or omit lipid; recheck fasting triglycerides
	Electrolyte imbalance	Hypo/hypernatraemia, hypokalaemia, hypo-phosphataemia	Daily electrolyte monitoring; adjust PN bag composition; IV replacement as needed
Hepatic	PN-Associated Liver Disease (PNALD / IF-ALD)	Rising ALP, bilirubin; steatosis; cholestasis on long-term PN	Cycle PN 16–18 h/day; use lipid minimisation; try enteral feeding even small volumes; consider fish-oil lipid (SMOF)
Infective	CLABSI (catheter-related bloodstream infection)	Fever, rigors, signs of sepsis; no obvious source	CLABSI bundle (see below); blood cultures; consider line removal; antibiotics per micro

CLABSI Prevention Bundle

        1. Hand hygiene  |  2. Maximal sterile barrier precautions on insertion  |  3. Chlorhexidine skin antisepsis  |  4. Optimal insertion site (subclavian preferred over femoral)  |  5. Daily review of line necessity — remove when no longer needed
      

📈 Monitoring on Parenteral Nutrition

Parameter	Frequency	Target / Action
Blood glucose	Every 4–6 h initially; then every 6–8 h once stable	Target 6–10 mmol/L in ICU; 6–12 mmol/L ward
Electrolytes (Na, K, Mg, PO4)	Daily (more in refeeding / critically ill)	Replace as per protocol; adjust PN bag
Renal function (urea, creatinine)	Daily initially; then 2–3× weekly	Adjust PN protein if deteriorating renal function
LFTs (ALT, ALP, bilirubin)	Twice weekly	Rising LFTs — investigate PNALD; cycling; minimise lipid
Triglycerides	Weekly (or if visually lipaemic)	<4.5 mmol/L; reduce lipid if elevated
Weight / fluid balance	Daily	Adjust PN volume accordingly
CVC insertion site	Every shift	Signs of infection, phlebitis, displacement
Line dressing integrity	Every shift; change 7-day or when soiled	Chlorhexidine-impregnated dressings preferred

🧠 Pathophysiology of Refeeding Syndrome

        Starvation: Body depletes carbohydrate stores; shifts to fat/protein catabolism; intracellular depletion of phosphate, potassium, magnesium (though serum levels may appear normal)

        Refeeding (carbohydrate load): Insulin surge → cellular uptake of glucose, phosphate, K, Mg → Serum levels plummet

        Consequences of hypophosphataemia: ATP synthesis failure → Cardiac failure, respiratory failure (diaphragm weakness — failure to wean from ventilator), haemolysis, seizures, rhabdomyolysis, peripheral oedema

💊 Prevention Protocol

Before Starting Feeds

Identify risk using NICE criteria (above)
Check baseline: phosphate, potassium, magnesium, glucose, Na, urea
Thiamine 200–300 mg IV immediately before feeds (not oral — absorption unreliable in malnourished)
Correct significant electrolyte deficits before starting
Ensure adequate fluid resuscitation

During Refeeding

Start at 10–15 kcal/kg/day (maximum) in high-risk patients
Increase by 33% every 2 days toward target over 4–7 days
Continue thiamine for 10 days (oral or IV)
Monitor phosphate, K, Mg, glucose daily for minimum 2 weeks
Replace electrolytes IV or enterally as needed
Strict daily fluid balance and weight

🚨 Treatment of Refeeding Syndrome

Electrolyte Abnormality	Threshold	Action
Hypophosphataemia	<0.6 mmol/L	IV phosphate replacement (e.g. Addahos 20 mmol over 12 h); STOP or markedly reduce feeds; recheck in 6 h
Hypophosphataemia	0.6–0.8 mmol/L	Oral phosphate supplements; reduce feed rate; monitor 12-hourly
Hypokalaemia	<3.0 mmol/L	IV potassium replacement; cardiac monitoring; reduce feed rate
Hypomagnesaemia	<0.5 mmol/L	IV magnesium sulphate; magnesium deficiency impairs potassium/phosphate correction
Thiamine deficiency (Wernicke)	Clinical suspicion	High-dose IV thiamine (Pabrinex 2 pairs TDS for 3 days); do NOT delay for blood results

Cardiac arrest risk: Phosphate <0.3 mmol/L is a medical emergency. Stop feeding immediately. Contact medical team urgently. Cardiac monitoring. IV phosphate replacement.

👥 Special Populations at High Risk in GCC

Post-operative bariatric surgery patients with poor intake
Cancer patients on chemotherapy with severe mucositis/anorexia
Elderly patients admitted with prolonged poor oral intake (common in GCC — cultural preference for keeping unwell relatives at home)
Patients with undiagnosed or uncontrolled type 1 DM with prolonged starvation
Post-Ramadan patients who have combined fasting with underlying malnutrition
Chronic alcoholism (uncommon but present in expat population)
Anorexia nervosa — referral pathway under-developed in GCC region

🌍 Nutrition Challenges in GCC Healthcare

Nutrition Paradox: GCC countries have among the highest obesity/diabetes prevalence globally (UAE: ~37% obesity, KSA: ~35%), yet hospital malnutrition remains under-recognised and undertreated. Disease-related malnutrition and sarcopenic obesity co-exist.

Key Regional Issues

Malnutrition screening not universally embedded in admission processes across GCC hospitals
Dietitian workforce predominantly expatriate — workforce localisation ongoing
Language barriers with multinational patient population (Arabic, Urdu, Filipino, English)
Family-centred decision-making impacts EN/PN initiation discussions
End-of-life nutrition decisions culturally complex — feeding often seen as comfort/care

Regulatory Bodies

UAE: HAAD (Abu Dhabi), DHA (Dubai) — dietitian registration required
KSA: SCFHS (Saudi Commission for Health Specialties)
Qatar: QCHP (Qatar Council for Healthcare Practitioners)
Bahrain: NHRA (National Health Regulatory Authority)
Kuwait: Ministry of Health — MOH licensing
Oman: OMSB (Oman Medical Specialty Board)

🆙 Ramadan & Enteral Tube Feeding

        Ramadan is observed across the GCC. Clinicians and nurses must be prepared to sensitively discuss tube feeding and Ramadan with patients and families.
      

Scenario	Scholarly Position	Clinical Guidance
NG/PEG gastric feeding during Ramadan	Majority of Islamic scholars: intragastric feeding breaks the fast; patient may be exempt (marid = illness)	Discuss with patient, family, and hospital chaplain/religious authority. Critically ill patients: feeding takes clinical priority
Jejunal tube feeding (NJ/jejunostomy)	Minority of scholars: bypasses stomach therefore may not break fast; contested	Discuss on individual basis. Not a definitive ruling — clinical judgement required
Parenteral nutrition during Ramadan	Most scholars: IV nutrition does not constitute eating — does not break fast; some disagree	Seek local religious authority guidance; most GCC hospitals have fatwa committee
Patient on home PEG fasting	Patient is generally exempt (rukhsa) — illness exemption	Educate patient: feeding medically necessary; missed days may be compensated (fidya/qadha)

Key nursing action: Do not make religious assumptions for patients. Open, sensitive conversations with patient and family. Escalate to team and hospital chaplaincy service.

✅ Halal Certification of Enteral Formulas

        The majority of commercially available enteral formulas in GCC are now halal-certified. However, nurses should verify this at ward/pharmacy level as product lines vary.
      

Formula Brand	Halal Status (GCC)	Notes
Fresubin range (Fresenius Kabi)	Halal certified for GCC versions	Check country-specific pack — halal certification label present
Ensure / Ensure Plus (Abbott)	Halal certified	Abbott GCC products certified — verify on packaging
Jevity range (Abbott)	Halal certified	Contains porcine-free gelatin in GCC formulations
Nutrini (Nutricia — Danone)	Halal certified	Paediatric range — verify each product
Fortimel (Nutricia)	Halal certified (GCC)	Oral supplement range

Nurses should not assume halal status. Always check the product label or confirm with pharmacy/dietitian for each specific product batch, as formulations can change.

🏠 IDDSI — Texture-Modified Diets in GCC

        The International Dysphagia Diet Standardisation Initiative (IDDSI) framework standardises texture-modified food and drink terminology. Adoption is growing across GCC hospitals.
      

IDDSI Level	Name	Clinical Application
0	Thin	Normal fluid
1	Slightly thick	Mild dysphagia; slight resistance
2	Mildly thick (nectar)	Mild-moderate dysphagia
3	Moderately thick (honey)	Moderate dysphagia — careful oral feeding
4	Pureed / Extremely thick	Falls apart test on spoon; no chewing required
5	Minced & moist	Can be chewed with reduced effort
6	Soft & bite-sized	Soft cohesive pieces; needs some chewing
7	Regular	Normal food

IDDSI replaces older terminology (minced, puree, nectar-thick) with standardised descriptors. GCC nurses should be familiar with local hospital IDDSI policy and communicate using correct IDDSI level numbers.

🏭 Home Enteral Nutrition in GCC

Home PEG feeding is increasingly common with growing ageing and neurological disease population in GCC
Community nursing infrastructure for home EN is limited in most GCC countries — primarily family-managed
Nurses play key role in carer education before hospital discharge: feed preparation, pump use, tube care, troubleshooting, and when to seek help
Written instructions should be provided in patient's preferred language (Arabic, Urdu, Tagalog, English)
Home formula supply: available via pharmacy in Dubai/Abu Dhabi; community prescription systems improving in KSA/Qatar
Telehealth follow-up of home EN patients growing post-COVID in GCC — nurses can deliver remote support

Score: 0 / 0 answered

Q1.A 70 kg patient is admitted to ICU on Day 2 of critical illness. What energy target is most appropriate during the acute phase?

Correct. Critical illness acute phase (Days 1–7): 20–25 kcal/kg/day avoids over-feeding and reduces complications. Increase to 25–30 kcal/kg/day in the recovery phase.

Q2.You attempt to aspirate from an NG tube before starting a feed. The pH paper shows 6.5. What is your MOST appropriate next action?

Correct. pH >5.5 means position is NOT confirmed. A chest/abdominal X-ray is required. The whoosh test (auscultation) is unreliable and NOT recommended per NPSA guidance. Do not feed until position is confirmed.

Q3.Which of the following is a recognised risk factor for refeeding syndrome according to NICE criteria?

Correct. NICE criteria for high-risk refeeding syndrome include: BMI <16, unintentional weight loss >15% in 3–6 months, minimal/no nutritional intake >10 days, or low electrolytes (K, Mg, PO4) before feeding. Any ONE of these = high risk.

Q4.A patient on continuous NG feeding has a gastric residual volume (GRV) of 320 ml on your 4-hourly check. What is the most appropriate initial nursing action?

Correct. GRV 250–500 ml: reduce feed rate, consider prokinetic (metoclopramide or erythromycin), recheck in 2–4 hours. Stop feed only if GRV >500 ml. Return aspirate to avoid electrolyte loss.

Q5.Which is the MOST important electrolyte to monitor in the first 48 hours of refeeding a severely malnourished patient?

Correct. Hypophosphataemia is the hallmark and most dangerous feature of refeeding syndrome. As carbohydrates are introduced, insulin drives phosphate into cells, causing serum phosphate to plummet. Levels <0.3 mmol/L can cause cardiac arrest.

Q6.What is the maximum recommended osmolality for peripheral parenteral nutrition (PPN) to prevent thrombophlebitis?

Correct. Peripheral PN must have osmolality <900 mOsm/L to minimise the risk of thrombophlebitis and vein damage. Central PN can accommodate much higher osmolalities (1200–1800 mOsm/L) safely via a large central vein.

Q7.A patient with a PEG tube complains the tube feels "stuck" and cannot be rotated. What should the nurse suspect?

Correct. Inability to rotate a PEG tube is a classic sign of buried bumper syndrome — the internal bumper has migrated into the gastric/abdominal wall. Do NOT force the tube. Refer urgently to the gastroenterology/surgical team.

Q8.What is the recommended protein target for a patient in ICU with acute kidney injury on continuous renal replacement therapy (CRRT)?

Correct. CRRT causes significant amino acid losses in the effluent. Protein requirements are markedly higher (1.5–2.5 g/kg/day) compared to CKD without dialysis. Restricting protein in CRRT patients leads to worsening catabolism and worse outcomes.

Q9.You are hanging a new PN bag and notice the bag appears to have two visible layers (white lipid layer separated from yellow aqueous layer). What should you do?

Correct. Phase separation in an AIO PN bag indicates the emulsion has broken down — the bag is unstable and MUST NOT be administered. Return to pharmacy for a replacement bag. Administration of a destabilised bag can cause fat emboli and life-threatening complications.

Q10.Which vitamin MUST be given intravenously BEFORE starting enteral or parenteral feeds in a patient at high risk of refeeding syndrome?

Correct. Thiamine (Vitamin B1) MUST be given IV (200–300 mg) immediately BEFORE starting any feed in high-risk refeeding patients. Carbohydrate metabolism requires thiamine — starting feeds without it can precipitate Wernicke's encephalopathy. Oral thiamine absorption is unreliable in malnourished patients.