© 2007 Thomson - Wadsworth Chapter 15 Enteral & Parenteral Nutrition Support.

© 2007 Thomson - Wadsworth

Chapter 15

Enteral & Parenteral Nutrition Support


Nutrition Support

• Enteral• Means “within or by

means of the gastrointestinal tract.”

OralKnown as tube

feedingsPreferred route if

have adequate GI function

• ParenteralUses the veinsPersons with

inadequate GI function


If you choose enteral nutrition support…

• Must have functional GI tractBowel sounds

• Can be used alone or as a supplement

• Variety of kinds of formulas

• TypesStandard (1.0-1.2cal/ml)

• Tolerated by most patients

Hydrolyzed• Partially or fully broken down• Persons with compromised GI

functioning

High calorie Disease-specificModular

• contain 1-2 macronutrients


Enteral Nutrition Support

• Provide Pro, CHO and Fat

• Nutrient Density Protein = 8-29% of

total kcaloriesStandard formulas

• Carbohydrates = 40-50% total kcalories

• Fat = 30-45% total kcalories

• Energy Density0.5-2.0 kcalories per mLStandard formulas

• 1.0-1.2 kcalories per mL• Patients with average

fluid requirements

Formulas with higher energy density

• Smaller amount of fluid• Good for fluid restrictions


Feeding Routes

• Tube feeding less than 4 weeks Nasogastric

• Postplorically Nasoduodenal Nasojejunal These tubes are weighted

or non-weighted with stylets to guide placement

• Orogastric Mouth to stomach Good for vent patients

• Tube feeding more than 4 weeks

• Enterostomy Gastrostomy Jejunostomy

• Gastric feedings are the preferred route Easily tolerated & less

complicated Not good for patients at

risk for aspiration


Osmolality

• A solution’s tendency to shift from one fluid compartment to another across a semipermeable membrane

• Range: 300-700 milliosmoles per kilogram • Isotonic: osmolality similar to blood• Hypertonic: osmolality greater than blood


Enteral Nutrition in Medical Care

• Preferred over parenteralHelps maintain gutFewer

complicationsLess costly

• Oral preferred over tube feedingsLess stressLess complicationsLess costly

• Can fully meet nutrient needs

• Good for weak & debilitated patients

• Nurses help patients find appealing flavors


Candidates for Tube Feedings

• Severe swallowing problems

• Little or no appetite• GI obstructions,

impaired GI motility• Intestinal

resections

• Mentally incapacitated

• Coma • Extremely high

nutrient requirements

• Mechanical ventilators


Feeding Tubes

• Soft & flexible• Variety of lengths & diameters• Outer diameter measured in French units


Formula Selection

• Need to assessAgeMedical problemsNutritional statusAbility to digest &

absorb nutrients

• Choose the oneWith the lowest risk

of complicationsLowest cost

• Nutrition-related factorsEnergy, protein, &

fluid requirementsNeed for fiber

modification Individual tolerances

(food allergies & sensitivities)

What Formula?

• Factors to considerGI functionCalorie and protein

densityAbility to meet needsType of

• Protein, fat, CHO• Fiber

ElectrolytesFluidViscosityOsmolality



Administration of Tube Feedings

• Safe handling Clean equipment Clean hands

• Open system Formula needs to be

transferred from original packaging to feeding container

• Closed system Formula is prepackaged

• Safety guidelines Clean can opener & lid Refrigerate unused portions

in clean, closed containers Discard unlabeled or

unused within 24 hours Open system; hang no

longer than 8-12 hour supply

Closed system; hang no longer than 24-48 hour supply


Tube Feeding

• Initiating tube feeding Discuss with patient

& family Check initial

placement with X-ray Monitor its position

throughout the day: can check fluid pH

• Formula delivery Intermittent

• Gastric, 2500-400 mL over 20-40 minutes

• Risk of aspiration Bolus

• Gastric • Delivery of <500mL every 3-4

hours Continuous

• Slowly at constant rate• 8-24 hours• Noctural


Administering the Feeding

• Formula volume & strengthVaries among

institutionsHypertonic fluids

usually started slowly & volume gradually increased

Assess patient tolerance

• Checking gastric residualsWithdraw contents

through feeding tube with syringe

Intermittent before each feeding

Continuous every 4-6 hrs


Tube Feedings

• Supplemental waterFormulas are 69-

85% waterMore water comes

from flushes via feeding tubes

• Flush before & after each bolus or intermittent feeding

• Flush every 4 hours for continuous

• Count as intake

• Transition to table foodsGradually shift to

oral dietOral needs to be

2/3 of nutrient intake before discontinuing the tube


Tube Feedings

• Delivering medicationsNeed to consider

diet-drug interactionsMedications can clog

tubesContinuous: stop

feeding 15 minutes before & after medication administration

• ComplicationsNausea & diarrheaMechanical problemsMetabolic problems

• Monitor patient’sWeightHydration statusLab test results

Parenteral Nutrition Support



Indications for Parenteral Nutrition

• Short bowel syndrome

• Severe pancreatitis

• Malabsorption disorders

• Intestinal obstructions or fistulas

• Severe burns or trauma

• Critical illnesses or wasting disorders

• Bone marrow transplants

• Malnourished & high risk for aspiration


Venous Access

• Peripheral Parenteral Nutrition (PPN)Peripheral veinsShort-term support Patients with average

nutrient needs & no fluid restrictions

Veins can be damaged

• Need solutions under 800-900 mOsm

• Total Parental Nutrition (TPN)Larger, central

veinsLong-term supportPatients with high

nutrient needs or fluid restrictions


Parenteral Solutions

• Contain amino acidsAll essential plus

combinations of non-essential

• Contain carbohydratesDextrose, 3.4

kcalories/gram2.5-70% concentrations>10% only for TPN

• Contain lipidsSignificant source of

energy10, 20% solutionsOften provided daily &

= 20-30% total kcalories

Decreases risk of hyperglycemia from dextrose



• FluidNeed 1500-2500

mL/day for adults

• Contain electrolytes Sodium, potassium,

chloride, calcium, magnesium, & phosphorus

Expressed in milliequivalents (mEq)

• Contain vitaminsAll water-soluble plus A,

D, & EK must be added

separately

• Contain trace mineralsZinc, copper, chromium,

selenium, & manganese Iron is excluded


Types of Parenteral Solutions

• Total Nutrient Admixture (TNA)3-in-1 solutionAlso called “all-in-one” solutionContains dextrose, amino acids, & lipids

• 2-in-1 solutionDextrose & amino acidsLipids administered separately to

provide essential fatty acids


Administering Parenteral Nutrition

• Team effort Physicians Dietitians Pharmacists Nurses: provide direct

care

• IV catheters Nurse can place in

peripheral veins Physician must place

in central veins

• Problems DislodgingAir embolismClotting Phlebitis Infection

• Must use aseptic technique

Parenteral Nutrition Complications

• Mechanical complications• Infection and sepsis• Metabolic Complications• Gastrointestinal Complications




• AdministeringContinuous

• Critically ill• Malnourished

Cyclic • 10-16 hours• Often provided at

night

Check tubing & solution daily for contamination

• DiscontinuingWhen 2/3-3/4 of

nutrient needs are provided by enteral feedings, IV can be discontinued

Clear liquids Small enteral

feedings to determine tolerance


Managing Metabolic Complications

• Hyperglycemia Patients who are glucose

intolerant or in severe metabolic stress

Provide insulin with feedings or decrease dextrose

• Hypoglycemia When feedings are

interrupted or discontinued

Taper slowly

• Hypertriglyceridemia Critically ill can’t tolerate

lipid infusions Impaired lipid clearance

• Refeeding syndrome Re-feed slowly Life-threatening

• Abnormal liver function Long-term, can lead to

liver failure Cause unclear


Managing Metabolic Problems

• Gallbladder diseaseParenteral for more

than 4 weeksSludge builds up,

leading to gallstonesCholecystokinin

injections or remove gallbladder

• Metabolic bone diseaseLong-term

parenteral lowers bone density

Alterations in calcium, phosphorus, & vitamin D metabolism


Nutrition Support at Home

• CandidatesEnteral

• Head & neck cancers• Neurological

impairments affecting swallowing

Parenteral• Portion of small

intestine removed• Intestinal obstructions• Malabsorption

conditions

• Planning EnteralNasal tubes or

enterostomies Investigate cost &

availability

• Planning ParenteralSterile & aseptically

preparedCyclic best


Quality of Life Issues

• Economic impact• Time-consuming• Inconvenient• Disturbed sleep• Activities & work

must be planned around feedings

• Social issues Inability to

consume meals with friends & family

Inability to go to restaurants & social events

Fear, anxiety & depression


Nutrition in Practice

Ethical Issues in Nutrition Care


Ethical Principles & Health Care

• Patient autonomy The right to make own

health care decisions

• Disclosure Fully informed of

treatment’s risks & benefits

• Decision-making capacity Mental capacity to

make appropriate health care decisions

• Treatment benefits (beneficence) should outweigh harm (maleficence)

• Distributive justice Would care given to one

patient unfairly limit the care of other patients?


Life-Sustaining Treatments

• Nutrition support & hydration

• Cardiopulmonary resuscitation (CPR)

• Defibrillation• Mechanical ventilation• Dialysis


Legal Documents for End of Life Care

• Living will, medical directive Written statement

specifying medical procedures desired or not desired

• Advanced directive Written or oral

instruction regarding one’s preferences for medical treatment

• Durable power of attorney Another person is

appointed to make health care decisions in the event of incapacitation

• Do-not-resuscitate (DNR) Order to withhold CPR in

the event of a cardiac arrest

© 2007 Thomson - Wadsworth Chapter 15 Enteral & Parenteral Nutrition Support.

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Transcript of © 2007 Thomson - Wadsworth Chapter 15 Enteral & Parenteral Nutrition Support.