Diet Instruction: Enteral Tube Feeding

Etiology:

Enteral nutrition is used when a patient is severely underweight and/or

malnourished. It can only be prescribed if the patient has a fully or partially functioning

gastrointestinal tract. If not, the patient must be placed on parenteral nutrition. There are

three different types of feeding tubes for enteral nutrition. These include the nasogastric,

gastrostomy, and jejunostomy tubes. The type of tube that a patient receives depends on

if the tube will be temporary or permanent. It also depends on which part of the

gastrointestinal tract is functioning. Enteral tube feedings can be safely and effectively

performed at home if the patient is given instruction by a health professional

(www.nestle-nutrition.com).

Some health conditions that can require enteral nutrition are gastrointestinal

disorders, cardiopulmonary disorders, hyper-metabolism, and neuromuscular disorders

(www.nutritioncare.org). My patient has Dysphagia and she is placed on enteral tube

feedings to ensure that she is getting her necessary daily caloric and nutrient intakes.

Dysphagia is more prevalent in the elderly population (www.nidcd.nih.gov). It is

usually seen as a symptom caused by a variety of disorders instead of as a disease state

(Nelms 354-355). Dysphagia is defined as “any condition that weakens or damages the

muscles and nerves used for swallowing (www.nidcd.nih.gov). Diseases of the nervous

system such as cerebral palsy, multiple sclerosis, and Parkinson’s disease can cause

dysphagia (www.nlm.nih.gov). Stroke or head injury can affect the ability of the

necessary muscles for swallowing or they can reduce sensations in the individual’s mouth

or throat. Some forms of cancer and even some treatments of cancer can cause dysphagia

as well (www.nidcd.nih.gov).

Diagnostic Measures:

Dysphagia is first diagnosed with a clinical bedside evaluation and a bedside

swallowing assessment. A healthcare team usually performs the diagnosis. The team

typically consists of physicians, nurses, a speech language pathologist, a physical

therapist, and an occupational therapist. The diagnosis is confirmed by performing either

a videofluoroscopy swallowing study or a fiber optic endoscopic swallowing evaluation.

For either diagnostic procedure, barium is added to a range of foods and beverages with

differing textures. Barium can be viewed by fluoroscopy or x-ray. This makes it possible

to monitor the movement of the food or beverage with barium. Barium is used to pinpoint

the specific location of dysphagia. Knowing the location makes it possible for the

healthcare team to establish an appropriate treatment plan (Nelms 355-356).

In Rose’s case, she has been diagnosed with inadequate oral food and beverage

intake related to her dysphagia. She has also been diagnosed with difficulty swallowing

and malnutrition.

Treatment:

Medical, surgical and/or psychological treatment:

The patient had a gastrostomy to insert a permanent gastric tube. The gastric tube

is being used for enteral tube feedings. The patient could receive treatment from a variety

of health professionals. The patient can be referred to a psychiatrist since she is going

through depression due to her inability to swallow and chew food. She can see a speech

pathologist or an occupational therapist in order to improve her chewing and swallowing

abilities. This can sometimes be attained by practicing muscle exercises to strengthen

facial muscles or to improve muscle coordination (www.nidcd.nih.gov).

Medical Nutrition Therapy:

The medical nutrition treatment therapy for the patient with dysphagia depends on

the cause and the severity. In Rose’s case, her dysphagia is preventing her from receiving

adequate oral intake. In order to bypass the passage of foods or beverages through the

esophagus, Rose is placed on enteral tube feeding. She is placed on enteral nutrition

because she had severe weight loss in the past 6 months. Enteral nutrition is chosen

instead of parenteral nutrition because Rose has a functioning gastrointestinal tract. A

gastrostomy was performed because Rose will need to be on long-term enteral nutrition.

Gastric tube feeding will also allow for bolus feedings, which mimic a regular eating

schedule (Nelms 85).

Before determining Rose’s enteral prescription, her fluid and electrolyte balance

must be restored. Her poor skin turgor and dry skin are evidences of dehydration. Her

electrolyte values are all elevated and this is common in individuals with dehydration.

Her hydration status has to return to normal in order for the electrolyte level readings to

be accurate.

Enteral formulas are typically the primary source of water for patients so it is

important to maintain an adequate fluid intake (Nelms 87). It is also recommended that

the patient consumes 2 cups of water per day to make sure that she is getting enough

fluid. Her enteral formula has 85% free water. Rose will use Nutren 1.0 and she will give

herself 5 bolus feedings a day. She will use 6 ½ cans of formula each day; this is

approximately 1 can and 1/3 cup of formula per feeding. She will be instructed on the

syringe method for bolus feeding at home. In order to make sure that there are no

complications with enteral feeding at home, she will monitor her weight once a week, her

hydration status at least 3 times a week, and her vital signs at least 3 times a week. She

will have her blood glucose levels measured every 2 weeks (Nelms 91). She will be

monitored closely for aspiration because her unstable mental state puts her at a higher

risk of developing it.

Description of patient and diagnosis:

Patient name: Rose Bush

DOB: 07/10/1942

Age: 72 y/o

Height: 5’ 4”

Weight: 120 lbs.

Sex: Female

Education: Bachelor’s Degree

Occupation: Retired business owner

Household members: daughter age 40, son-in-law age 41, granddaughter age 10

Ethnic background: Caucasian/ white

Chief Complaints

Patient: “I am embarrassed to eat in front of my friends and family members because I

take a long time to chew my food and my food does not always make it into my mouth.

Sometimes I drool and I think it is impolite to do that.”

Patient’s mother: “Lately she pushes her food around on her plate more than she eats it.

She is getting very thin and she seems depressed. She is very quiet during meals.”

Patient History

Onset of disease: Rose is a 72 year old female who had a stroke 7 months ago. She has

recovered from the stroke, but she had severe weight loss. In 6 months, she dropped from

145 pounds to 120 pounds (17.2% weight loss). She was admitted to the hospital for tests.

Rose complained of pain while swallowing and difficulty chewing. She was diagnosed

with Dysphagia and the doctor recommended a gastrostomy to insert a permanent feeding

tube. Rose is recovering from the gastrostomy and she has been administered enteral tube

feedings. Rose will be released from the hospital tomorrow. She will continue enteral

tube feedings at home. She needs instruction from a R.D. on how to perform the tube

feedings at home.

Physical Exam Upon Admission

General appearance: tired-looking woman, c/o fatigue and difficulty swallowing

Vitals:

HEENT

Heart: tachycardia

Eyes: sunken, membranes dry

Ears: membranes dry

Nose: dry mucous membranes

Throat: dry, inflamed

Neurologic: irritable, confused

Skin: poor turgor, dry skin

Chest/lungs: deep, rapid respiration

Biochemical Lab Values

1 day post-op

Electrolyte Current Serum Level Normal Serum Level

Sodium 151 mEq/L 136-146 mEq/L

Potassium 5.5 mEq/L 3.5-5.0 mEq/L

Chloride 110 mEq/L 98-106 mEq/L

Glucose 160 mg/dL 70-120 mg/dL

5 days post-op

Electrolyte Current Serum Level Normal Serum Level

Sodium 140 mEq/L 136-146 mEq/L

Potassium 4.0 mEq/L 3.5-5.0 mEq/L

Chloride 108 mEq/L 98-106 mEq/L

Glucose 122 mg/dL 70-120 mg/dL

Patient 24- hour recall

breakfast: ½ mashed banana, 8 oz. whole milk, 1/3 c. instant oatmeal

snack: 1 c. applesauce

lunch: ¾ c. mashed potatoes with gravy, 16 oz. water, ½ c. creamed corn

snack: skipped because her throat was very sore

dinner: 3 oz. meatloaf with gravy, 8 oz. Coca-Cola, ¼ rolled biscuit

snack: ½ c. pudding, 8 oz. water

Enteral Nutrition Prescription

Adjusted Body Weight Calculation:

AdBW=.25 (120 lbs.-145 lbs.) + 145 lbs.

AdBW=139 lbs.

139 lbs./2.2=63.2 kg

“dosing wt.”=63.2 kg

Mifflin-St. Jeor calculation for women:

wt=63.2 kg

ht= 162.6 cm

age=72 yrs.

10 (63.2 kg) + 6.25 (162.6 cm) – 5 (72 yrs.) – 161

1,127 kcal/day

PAL=1.4 (some seated work)

1,127 kcal*1.4= 1,578 kcal/day

Protein Goal:

RDA for older adults is 1.0 g/kg so Rose needs 63 kg protein/ day

63 kg pro *4=252 kcal

252 kcal/1,580 kcal*100=16 % pro

Electrolyte Needs:

There are no abnormal electrolyte losses so electrolyte needs should follow the RDA for

adults over 70 years old.

Sodium: 1,200 mg

Potassium: 4,700 mg

Chloride: 1,800 mg

Vitamin and Mineral Needs:

DRIs for adults 70 years and older

Vit. A: 700 mcg/day

Vit. C: 75 mg/day

Vit D: 15 mg/day

Calcium: 1,200 mg/day

Iron: 8 mg/day

Fluid Needs:

Patient’s hydration status has been restored

1,580 kcal* 1 mL=1,580 mL

osmolality should be about 300 mOsm/kg water

Enteral Formula Prescription:

The patient will receive 1,580 mL or Nutren 1.0 daily

Nutren 1.0:

1.0 kcal/mL

16% pro

51% CHO

33% fat

osmolality=370 mOsm/kg water

meets 100% for 20 key micronutrients

Continuous Feeding:

1,580 kcal/24 hrs.=66 mL/hr.

Bolus feedings 5 times/day:

1,580 mL/4=316 mL

250 mL/can of Nutren 1.0

316 mL/250 mL=1.3 cans

1 can and 75 mL per bolus feeding (1.3 cans)

household measurements: approx. 1 can and 1/3 cup

Prognosis:

If the patient’s swallowing ability improves and her throat pain decreases, she will

be able to switch to a diet with partial oral intake (Nelms 358). The oral intake would

follow the NDD (National Dysphagia Diet) Level 1, which includes only pureed foods or

smooth foods with no lumps (www.anfponline.org). The food should have a “pudding-

like consistency (Nelms 357).” The patient will be educated by a R.D. on her modified

enteral tube feedings and appropriate foods for NDD Level 1. If the patient has trouble

tolerating the NDD Level 1, she will return to a full enteral tube feeding diet.

(Educational Materials)

At-Home Gastric Tube Feeding Overview

*Patient will decide times for feedings; feedings should be at least 2-3 hours apart

Your Formula: Nutren 1.0

Cans per day: 6 ½

Amount per feeding: 1 can and 1/3 c.

Your feeding schedule: 5 bolus feedings daily (at least 15 min. per feeding)

Times Amount of formula

AM 1 can and 1/3 cup

AM 1 can and 1/3 cup

AM/PM 1 can and 1/3 cup

PM 1 can and 1/3 cup

PM 1 can and 1/3 cup

Wash your hands thoroughly with soap and water then gather supplies:

formula

syringes

lukewarm water (1 cup)

feeding bag (if using)

feeding pump (if using)

Things to remember:

You must flush the tube before and after administration of formula or

medications.

if the tube becomes clogged, take immediate action to unclog it.

Store unopened cans of formula at room temperature.

When a can is opened, use immediately. Date and refrigerate the unused

portion, but it must be thrown away if it is not used within 24 hours.

Syringes need to be cleaned with warm, soapy water and left to air dry

between each use.

Bolus Feeding: Syringe Method

1. Draw up 60 ml of warm water in the syringe. Gently flush the water

through the tube to make sure the feeding tube is clean and open. Disconnect the

syringe. Recap the end of the feeding tube.

2. Remove the plunger from the syringe.

3. Uncap the feeding tube.

4. Attach the syringe directly to your feeding tube. Pour 1 can and 1/3 cup of

feeding into the syringe, allowing it to flow freely until all of the feeding is given.

5. Take the syringe and draw up 60 ml warm water. Gently flush the water through

the tube again to make sure the tube is clean and open. This water also helps keep

you hydrated.

6. Disconnect the syringe from the feeding tube.

7. Recap the feeding tube.

6. Repeat the procedure 4 more times. If you do not tolerate the prescribed amount

of formula, notify your dietitian.

Helpful Resources:

American Society for Parenteral and Enteral Nutrition (ASPEN)

Nestle Health Science: Medicare Coverage of Enteral Nutrition Therapy

References

Academy of Nutrition and Dietetics. (2014). Nutrition Care Manual. Retrieved from http://www.nutritioncaremanual.org

American Gastroenterological Association. (1995). American gastroenterological position statement: guidelines for the use of enteral nutrition. Retrieved from http://www3.us.elsevierhealth.com/gastro/policy/v108n4p1280.html

American Society for Parenteral and Enteral Nutrition. (2013). What is enteral nutrition? Retrieved from http://www.nutritioncare.org/Information_for_Patients Cleveland Clinic. (n.d.). Tube-feeding instructions for home. Retrieved from www.my.clevelandclinic.org./home-enteral-nutrition-booklet.pdf Dietary Manager. (2004).Understanding and implementing dysphagia diets. Association of Nutrition & Foodservice Professionals. Retrieved from http://www.anfponline.org/Publications/articles/2004_03_008Dysphagia Fletcher, J. (2011). Nutrition: safe practice in adult enteral tube feeding. British Journal Of Nursing, 20(19), 1234-1239. Retrieved from http://eds.b.ebscohost.com.proxy.lib.muohio.edu Lloyd, D. & Powell-Tuck, J. (2004). Artificial nutrition: Principles and practices of

enteral feeding. Clinics in Colon and Rectal Surgery, 17(2), 107–118.

doi: 10.1055/s-2004-828657

National Institutes of Health. (2010). Dysphagia. National Institute on Deafness and Other Communication Disorders. Retrieved from http://www.nidcd.nih.gov/health/voice/Pages/dysph.aspx Nelms, M., Sucher, K., Lacey, K., & Roth, S. (2011). Nutrition therapy & pathophysiology 2/e. Belmont, CA: Wadsworth, Cengage Learning. Nestle Health Science. (2013). Best practices in enteral feeding safety. Retrieved from http://www.nestle-nutrition.com/Products