Chapter 15 Enteral and Parenteral Nutrition Support

Enteral and Parenteral NutritionSupport

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Introduction

• Nutrient delivery for patients too sick to consume a normal diet

• Enteral nutrition– Tube feedings directly to the stomach or small

intestine• Parenteral nutrition

– Nutrients provided intravenously• When possible, why is enteral preferred

over parenteral?Copyright © 2017 Cengage Learning. All Rights Reserved.


Enteral Nutrition

• Oral supplements– Primary nutrition problem: poor appetite– Adequate nutrition by this means avoids

stress, complications, and expense of tube feedings

– Box 15-2 provides tips for improving intakes with oral supplements



Enteral Nutrition (cont’d.)

• Candidates for tube feedings– Severe swallowing disorders– Impaired motility in the upper GI tract– GI obstructions and fistulas that can be

bypassed with a feeding tube– Certain types of intestinal surgeries– Little or no appetite for extended periods




• Candidates for tube feedings– Extremely high nutrient requirements– Mechanical ventilation– Mental incapacitation due to confusion,

neurological disorders, or coma– What conditions are contraindications for tube

feeding?




• Tube feeding routes (Box 15-3)– Factors in selecting feeding route

• Patient’s medical condition• Expected duration of tube feeding• Potential complications of a particular route



Tube Feeding Routes



Enteral Nutrition: Tube Feeding Routes (cont’d.)

• Gastrointestinal access– Tube feeding for <4 weeks

• Nasogastric or nasointestinal route• Feeding tube passed into the GI tract via the nose

– Feeding tube tip placement• Nasogastric (stomach)• Nasoduodenal or nasojejunal (small intestine)




• Gastrointestinal access– Infants: orogastric placement sometimes

preferred over transnasal routes– Direct route to stomach or intestine

• Tube feeding >4 weeks• Inaccessible nasointestinal route• Types of direct routes: enterostomy, gastrostomy,

or jejunostomy




• Selecting a feeding route (Table 15-1)– Based on duration

• Transnasal access for <4 weeks and enterostomies for longer periods

– Gastric feedings (nasogastric and gastrostomy routes)

• Preferred whenever possible• Avoided in patients at high risk of aspiration




• Feeding tubes– Soft, flexible materials – Tube selection factors

• Patient’s age and size, the feeding route, and the formula’s viscosity

– Outer diameter measured in French units• 1 French unit = 1/3 mm; 12 French = 4 mm

– Double-lumen tubes• Intestinal feedings and gastric decompression




• Enteral formulas (Appendix G)– Types of enteral formulas

• Standard formulas: patient can digest and absorb nutrients without difficulty

• Elemental formulas: patients who have compromised digestive or absorptive functions

• Specialized formulas: meet the specific nutrient needs of patients with particular illnesses

• Modular formulas: patients who require specific nutrient combinations to treat their illnesses



Enteral Nutrition: Enteral Formulas (cont’d.)

• Macronutrient composition– Protein: 12% to 20% of total kcalories– Carbohydrate: 30% to 60% of kcalories– Fat: 15% to 30% of kcalories

• Energy density– 1.0 to 2.0 kcalories per milliliter of fluid

• Fiber content– Formulas with or without fiber




• Osmolality: moles of osmotically active solutes (or osmoles) per kg of solvent– Isotonic formula: osmolality similar to blood

serum– Hypertonic formula: osmolality greater than

blood serum– Most enteral formulas: 300 to 700

milliosmoles per kilogram




• Formula selection (Figure 15-3)– GI function– Nutrient and energy needs– Fluid requirements– Need for fiber modifications– Individual tolerances (food allergies and

sensitivities)




• Safe handling– Facility-specific protocols– Open feeding system vs. closed feeding

system• Formula safety guidelines

– What steps can reduce the risk of formula contamination when using open feeding systems?




• Administration of tube feedings– Preparing for tube feedings

• Fully discuss the procedure with the patient and family members

• Box 15-5 offers tips for talking to patients• Use X-rays to verify tube placement before

initiating feeding• Elevate patient’s upper body (30- to 45-degrees,

during + 30-60 min after) to reduce aspiration risk



Enteral Nutrition:Administration of Tube Feedings (cont’d.)

• Formula delivery methods– Intermittent feedings: 250-400 mL formula

delivered over 30-45 min (usually to stomach)– Bolus feedings: 250-500 mL over 5-15 min – Continuous feedings: slow, constant delivery

over 8-24 hours (usually to intestine)– Box 15-6 describes how to plan a tube

feeding schedule




• Initiating and advancing tube feedings– Formulas typically provided full-strength– Intermittent feedings: 60-120 mL at the initial

feeding; increase by 60-120 mL at each feeding until reaching the goal volume

– Continuous feedings: start at rates of 40-60 mL/hour; raise by 20 mL/hour every 8-12 hours until reaching the goal rate




• Initiating and advancing tube feedings– If the patient cannot tolerate an increased

delivery rate, feeding rate slowed until the person adapts

– Slower delivery rates better tolerated: critically ill patients; concentrated formulas used; patients who have undergone an extended period of bowel rest




• Checking the gastric residual volume– Volume of formula and GI secretions

remaining in the stomach after feeding• Meeting water needs

– Adult requirements: 30-40 mL/kg/day– Enteral formulas: 70% to 85% water

(700 to 850 mL of water per liter)– Water flushes contribute to fluid intake




• Medication delivery during tube feedings– Medications and continuous feedings

• Why are continuous feedings stopped prior to and after medication administration?

– Diarrhea• Medications are a major cause• Dilution of hypertonic medications may be helpful

– Box 15-8 provides further details




• Tube feeding complications (Table 15-2)– GI, mechanical, and metabolic problems– Many complications preventable by

appropriate selections:• Feeding route• Formula• Delivery method




• Transition to table foods– Transition steps depend on

• Patient’s medical condition• Type of feeding the patient is receiving

– Tube feeding discontinued when oral intake supplies ~2/3 of estimated nutrient needs



Parenteral Nutrition

• Candidates for parenteral nutrition– Intractable vomiting or diarrhea– Severe GI bleeding– Intestinal obstructions or fistulas– Paralytic ileus (intestinal paralysis)– Short bowel syndrome– Bone marrow transplants– Severe malnutrition and intolerance to enteral

nutrition



Parenteral Nutrition (cont’d.)

• Venous access– Peripheral parenteral nutrition (PPN)

• Nutrients via peripheral veins only• What can be done to prevent phlebitis?• Candidates for PPN

– Require short-term nutrition support– Do not have high nutrient needs or fluid restrictions




• Venous access– Total parenteral nutrition (TPN)

• Nutrients delivered via central veins• Preferred for cases requiring nutrient-dense

solutions or long-term parenteral nutrition• Central venous catheter placement




• Parenteral solutions– Often prepared by pharmacies located within

health care institutions (Figure 15-11)• Customize the solutions• Solutions have a limited shelf life

– Amino acids• Contain essential + nonessential amino acids• Concentrations: 3% to 20%



Parenteral Nutrition:Parenteral Solutions (cont’d.)

• Carbohydrate– Main source of energy: glucose (dextrose

monohydrate, 3.4 kcal/g)– Concentration examples:

• D5W (5% dextrose in water)• D5NS (5% dextrose in normal saline)




• Lipids– Lipid emulsions supply essential fatty acids– Significant source of energy– 10%, 20%, and 30% solutions: 1.1, 2.0, and

2.9 or 3.0 kcal/mL, respectively• Fluids and electrolytes

– Patient’s fluid needs adjusted according to daily fluid losses and hydration assessment




• Fluids and electrolytes– Electrolytes: sodium, potassium, chloride,

calcium, magnesium, phosphate– Electrolyte content measured in

milliequivalents (mEq)• Vitamins and trace minerals

– Why are preparations available that do not include vitamin K?




• Medications– Occasionally added directly to parenteral

solutions or infused through a separate port in the catheter (piggyback)

• Parenteral formulations– Total nutrient admixture (TNA): 3-in-1 solution

• Contains dextrose, amino acids, and lipids




• Parenteral formulations– 2-in-1 solution

• Contains dextrose and amino acids• Lipid emulsion is administered separately

– Box 15-15 walks through calculations• Osmolarity

– Components contributing most to osmolarity: amino acids, dextrose, and electrolytes




• Administering parenteral nutrition– Nutrition support teams

• Physicians, nurses, dietitians, and pharmacists– Insertion and care of intravenous catheters

• Peripheral vein placement: skilled nurse• Central vein placement: only qualified physicians• Patient may be awake and given local anesthesia• To relieve apprehension, explain procedure

beforehand



Parenteral Nutrition: Administering Parenteral Nutrition (cont’d.)

• Insertion and care of intravenous catheters– What are ways to reduce the risk of

complications?• Administration of parenteral solutions

– Method used to initiate and advance depends on the patient’s condition and the potential for complications

– Continuous vs. cyclic parenteral nutrition



Parenteral Nutrition: Administering Parenteral Nutrition (cont’d.)

• Discontinuing parenteral nutrition– Patient must have adequate GI function and

minimal risk for aspiration– Discontinued when 60% to 75% of nutrient

needs provided by other means– Suppressed appetite can make transition to

an oral diet difficult




• Managing metabolic complications– Hyperglycemia

• Provide insulin along with parenteral solutions• Avoid overfeeding or overly rapid infusion rates• Restrict the amount of dextrose in the solution

– Hypoglycemia• Taper off over infusions over several hours before

discontinuation



Parenteral Nutrition: Managing Metabolic Complications (cont’d.)

• Hypertriglyceridemia– Blood triglyceride levels >400 mg/dL: reduce

or stop lipid infusions• Refeeding syndrome

– Initiate at ½ energy needs; advance slowly– Monitor electrolyte and glucose levels when

malnourished patients begin receiving nutrition support




• Liver disease– Avoid giving the patient excess energy,

dextrose, or lipids, which promote fat deposition in the liver

– Monitor enzyme levels weekly




• Gallbladder disease– Possible prevention: initiate oral feedings

before problem occurs– Treatment: medications, gallbladder removal

• Metabolic bone disease– Possible interventions: PN adjustments,

nutrient supplements, medications, and physical activity



Nutrition Support at Home

• Candidates for home nutrition support– Home enteral nutrition

• Individuals who have disorders preventing food from reaching the intestines or interfering with nutrient absorption

– Home parenteral nutrition• Individuals who have disorders severely impeding

nutrient absorption or interfering with intestinal motility



Nutrition Support at Home (cont’d.)

• Planning home nutrition care– Home enteral nutrition

• Access sites• Administration methods• Formulas

– Home parenteral nutrition• TPN with catheter exiting through chest wall• Solutions



Nutrition Support at Home (cont’d.)

• Quality-of-life issues– Lifestyle adjustments– Sleep disturbances – Social implications– Support groups and counseling



Nutrition in Practice:Inborn Errors of Metabolism

• Role of nutrition therapy in treatment• Role of other treatments• Phenylketonuria

– Diagnosis: infant screening– Nutrition therapy: phenylalanine restriction

with adequate tyrosine• Galactosemia

– Nutrition therapy: galactose restriction


Chapter 15 Enteral and Parenteral Nutrition Support

Education

Transcript of Chapter 15 Enteral and Parenteral Nutrition Support