Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum)Tube feedingsMust have functioning GI tractIF THE GUT WORKS, USE IT!Exhaust all oral diet methods first.

EnteralImpaired ingestionInability to consume adequate nutrition orallyImpaired digestion, absorption, metabolismSevere wasting or depressed growth ParenteralGastrointestinal incompetency Hypermetabolic state with poor enteral tolerance or accessibility

ApplicableSite placementFormula selectionNutritional/medical requirementsRate and method of deliveryTolerance

The suitability of a feeding formula should be evaluated based on Functional status of GI tractPhysical characteristics of formula (osmolality, fiber content, caloric density, viscosity)Macronutrient ratiosDigestion and absorption capability of patientSpecific metabolic needsContribution of the feeding to fluid and electrolyte needs or restriction Cost effectiveness

2004, 2002 Elsevier Inc. All rights reserved.

Fungsi Sal CernaYa Tidak (1) Enteral NutrisiParenteral NutrisiShort-termNasogastricNasoduodenalNasojejunalLong-termGastristomyJejunostomi Fungsi sal cernaNormalcompromisedNutrisi standart Mencukupi (2) Tdk Mencukupi (3) Mencukupi (4) Farmula khususShort-termLong-term/retriksi cairan

TPNPPNFungsi sal cernaYa TDK

Peritonitis difus, obstruksi usus, muntah-muntah, ileus, diareBerlanjut ke makanan oralNutrisi parenteral sbg suplemen, dilanjutkan ke nutrisi enteral totalBerlanjut ke diet yang lebih kompleks dan makanan oral sesuai dgn penerimaan

Access (medical status)Location (radiographic confirmation)DurationTube measurements and durabilityAdequacy of GI functioning

Intake easily/accurately monitoredProvides nutrition when oral is not possible or adequateCosts less than parenteral nutritionSupplies readily availableReduces risks associated with disease state

Preserves gut integrityDecreases likelihood of bacterial translocationPreserves immunologic function of gutIncreased compliance with intake

GI, metabolic, and mechanical complicationstube migration; increased risk of bacterial contamination; tube obstruction; pneumothoraxCosts more than oral dietsLabor-intensive assessment, administration, tube patency and site care, monitoring

Access problems (tube obstruction)Administration problems (aspiration)Gastrointestinal complications (diarrhea)Metabolic complications (overhydration)

Can result from enteral feedsHigh-risk patientsPoor gag reflexDepressed mental status

Check gastric residuals if receiving gastric feedsElevate head of the bed >30 degrees during feedingsPostpyloric feedingNasoenteric tube placement may require fluoroscopic visualization or endoscopic guidanceTransgastric jejunostomy tube

Bolus300 to 400 ml rapid delivery via syringe several times dailyIntermittent300 to 400 ml, 20 to 30 minutes, several times/day via gravity drip or syringeCyclicvia pump usually at nightContinuousvia gravity drip or infusion pump *Determined by medical status, feeding route and volume, and nutritional goals

kcal/ml x ml given= kcal% protein x kcal= kcal as proteinkcal as protein x 1 g/4 kcal= g proteinExample: Patient drinks 200 cc of a 15.3% protein product that has 1 kcal/ml1 kcal/ml x 200 ml= 200 kcal0.153 % protein x 200 kcal= 30.6 kcal30.6 kcal x 1g protein/4 kcal= 7.65 g protein

Healthy adult: 1 ml/kcal or 35 ml/kgHealthy infant: 1.5 ml/kcal or 150 ml/kgNormal tube feeding: 1 kcal/ml; 80% to 85% waterElderly: consider 25 ml/kg with renal, liver, or cardiac failure; or consider 35 ml/kg if history of dehydration

LiquidsWater in foodWater from metabolismWith tube feeding, nurse will flush tube with water about 3 times dailyinclude this amount in estimated needsExample: flush with 200 cc tid

Continuous method = slow rate of 50 to 150 ml/hr for 12 to 24 hoursIntermittent method = 250 to 400 ml of feeding given in 5 to 8 feedings per 24 hoursBolus method = may give 300 to 400 ml several time a day (push is not desired)

Diameter of feeding tube is measured in French units1F = 33 mm diameterFeeding tube sizes differ for formula types and administration techniques.

PediatricsLow residueHigh proteinVolume restrictionDiabeticPulmonary/COPD

Blender digunakan untuk pasien normal atau dgn ggn sal cerna minimal; masih diperlukan absorbsi; mengandung karbohidrat-lemak-protein utuhPolimer dgn kekentalan penuh, viskositas rendah, osmolaritas 300-500mOsm/kg, 1-1,2 kcal/cc - susu - bebas laktosaMonomer untuk pasien dgn ggn sal.cerna yg membutuhkan nutrisi yg sdh dihidrolisis, osmolaritas ~ proses hidrolisis, 1-1,2 kcal/cc,

Nama dagangIndikasiDiabetasolDMEnsureDiit TKTP dengan rendah residuEntrasoCachesia dan pasien dg diit TKTPFalkaminIsufisiensi hati yang memerlukan asupan protein yang rendah terutama BCAAIsocalmalnutrisiNeprisholIsufisiensi ginjal bersama diit rendah proteinNutrisonPasien yang tidak bisa, tidak boleh, dan tidak mau makan dan minumPeptisolCachesia atau pasien yang memerlukan diit proteinPepti 2000 variantGangguan pencernaan dan absorbsi dg kebutuhan TKTPSustacalCachesia dan malnutrisi

2004, 2002 Elsevier Inc. All rights reserved.

Central accessTPN both long- and short-term placementPeripheral or PPNNew catheters allow longer support via this method limited to 800 to 900 mOsm/kg due to thrombophlebitis

Central sites: Internal jugularSubclavian veinFemoral vein

15- 30

Kcal required (10% dextrose max. PPN conc.)Fluid toleranceOsmolarityDurationCentral line contraindicated

2004, 2002 Elsevier Inc. All rights reserved.

Provides nutrients when less than 2 to 3 feet of small intestine remainsAllows nutrition support when GI intolerance prevents oral or enteral support

GI non functioningNPO >5 daysGI fistulaAcute pancreatitisShort bowel syndromeMalnutrition with >10% to 15 % weight lossNutritional needs not met; patient refuses food

GI tract worksTerminally illOnly needed briefly (

Avoid excess kcal (> 40 kcal/kg) Adultskcal/kg BWObeseuse desired BMI range or an adjusted factor

Adjusted IBW for obesityFemale:([actual weight IBW] x 0.32) + IBWMale:([actual weight IBW] x 0.38) + IBW

Carbohydrateglucose or dextrose monohydrate3.4 kcal/gAmino acids3, 3.5, 5, 7, 8.5, 10% solutionsFat10% emulsions = 1.1 kcal/ml20% emulsions = 2 kcal/ml

1.2 to 1.5 g protein/kg IBW mild or moderate stress2.5 g protein/kg IBW burns or severe trauma

Max. 0.36 g/kg BW/hrExcess glucose causes:Increased minute ventilationIncreased CO2 productionIncreased RQIncreased O2 consumptionLipogenesis and liver problems

4% to 10% kcals given as lipid meets EFA requirements; or 2% to 4% kcals given as lineoleic acidUsual range 25% to 35% max. 60% of kcal or 2.5 g fat/kg

Fluid30 to 50 ml/kgElectrolytesUse acetate or chloride formsto manage acidosis or alkalosisVitaminsTrace elements

Nama DagangIndikasiAminofusinKeadaan katabolik, seperti infeksi berat, luka bakar, cidera berat dengan balance nitrogen negatif Aminofusin PAEDNeonatus prematur dan bayi yang menderita defisiensi protein atau penyakit dengan peningkatan kebutuhan proteinAminofusin TPNKeadaan katabolik dengan balance nitrogen negatifAminolebanKeadaan ensefalopati pada penderita penyakit hati yang akut/kronis. Aminoleban tidak boleh diberikan pada keletihan ginjal yang berat dan gangguan metabolisme asamamino lainnyaAminovel 600/1000Status gizi yang tidak memadai dan memerlukan nutrisi parenteral seperti short bowel syndrome, anoreksia dan gangguan gastrointestinal yang beratAmiparenHiponatremia, malnutrisi, pra/pasca bedahEAS primerKeadaan azotemia, GGA, dan isufisiensi renalyang kronik. AES jugadapat diberikan pada penderita pasca dialisis untuk menggantikan asam amino yang hilang. Keadaan yang memerlukan nutrisi parenteral parsial

Intrafusin 10%Keadaan yangmemerlukan TPN jangka pendek dan parsial jangka panjang. Larutan ini dapat menstimulus sintesis albumin. Larutan intrafusin 10% dapat diberikan bersamaan dengan larutan yang mengandung kalori dan elektrolitIntrafusin 3,5% SX-E Cachesia dan malnutrisi yang memerlukan suplemen kalori dalam waktu lama seperti malnutrisi yang menyertai cedera otak berat. Intralipid tidak boleh diberikan pada pasien sislipidemia, insufisiensi hati yang berat dan syok mendadakIntralipid 105/20% (ivelip)Keadan yang memerlukan nutrisi parentaral perifer total atau parsial jangka pendek, pre/post operasi, sepsis, luka bakar, gagalginjal, neonatusPE 90Malnutrisi atau hipoproteinemia yang memerlukan pasokan asam amino, tidak boleh diberikan pada koma hepatikum, kelainan ginjal yang berat dan gangguan metabolisme asam amino dan intoleransi fruktosa yangherediterPan Amin GKeadaan yang memerlukan kalori lewat nutrisi parenteral total atau parsial khususnya selama metabolisme post agresiTriofusin 500Keadaan yangmemerlukan kalori dan elektrolit lewat nutrisi parenteral total dan parsial, pre dan post operasi, terapi infus KH

1. Multiply the grams of dextrose per liter by 5. Example: 50 g of dextrose x 5 = 250 mOsm/L2. Multiply the grams of protein per liter by 10. Example: 30 g of protein x 10 = 300 mOsm/L3. Fat is isotonic and does not contribute to osmolarity.4. Electrolytes further add to osmolarity. Total osmolarity = 250 + 300 = 500 mOsm/L

Total nutrient admixture of amino acids, glucose, additives3-in-1 solution of lipid, amino acids, glucose, additives

Start slowly (1 L 1st day; 2 L 2nd day)Stop slowly (reduce rate by half every 1 to 2 hrs or switch to dextrose IV)Cyclic give 12 to 18 hours per day

InfectionHemodynamic stabilityCatheter careRefeeding syndrome

HypophosphatemiaHyperglycemiaFluid retentionCardiac arrest

Weight (daily)Blood Daily Electrolytes (Na+, K+, Cl-) Glucose Acid-base status 3 times/week BUN Ca+, P Plasma transaminases

Blood Twice/week Ammonia Mg Plasma transaminases Weekly Hgb Prothrombin time Zn Cu Triglycerides

Urine: Glucose and ketones (4-6/day) Specific gravity or osmolarity (2-4/day) Urinary urea nitrogen (weekly)Other: Volume infusate (daily) Oral intake (daily) if applicable Urinary output (daily) Activity, temperature, respiration (daily) WBC and differential (as needed) Cultures (as needed)

PPN Site irritationTPN 1. Catheter sepsis 2. Placement problems 3. Metabolic

Energy Infant 50 to 60 kcal/kg/day maintenance 70 to 120 kcal/kg/day growthChild >1yr BEE 1to 8 yrs 70 to 100 kcal/kg/day 8 to 12 yrs 60 to 75 kcal/kg/day 12 to 18 yrs 45 to 60 kcal/kg/day Injury factors 1.25 mild stress 1.50 nutritional depletion 2.00 high stress

Protein: Infant 2.4 to 4 g/kg/day 1 year 1 to 8 years 1.5 to 2.0 g/kg/day 8 to 15 years 1.0 to 1.5 g/kg/day

Carbohydrate Infant preterm: 4 to 6 mg/kg/minute begin rate Term infants: 8 to 9 mg/kg/minute begin rateFat Infants: 0.5 to 1.0 g/kg/day min for EFA needs 2 to 3 g/kg/day maxVitamins and minerals: See tables in textbook

Fluid and electrolytes Infant: LBW 125 to 150 ml/kg/day 2 to 4 mmol/kg/day for electrolytes Other infants and children

Type of feeding formula and tubeMethod (bolus, drip, pump)Rate and water flushIntake energy and proteinTolerance, complications, and corrective actions Patient education

Plan any tubefeedings or parenteral nutrition around diet restrictions. IF the nutrient would be restricted on the oral diet, then it needs to be considered when planning any kind of nutrition support.

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