Specialized Nutrition Support: Enteral

1
Specialized Nutrition SupportEnteral
Parenteral Nutrition

• Chapter 16

2
Need for Nutrition Support

• Nutrition support delivery of formulated
  nutrients by feeding tube or intravenous infusion
• Enteral nutrition supplying nutrients using GI
  tract, including tube feedings oral diets
• Parenteral nutrition intravenous provision of
  nutrients, bypassing the GI tract

• Nutrition support may be required to meet
  patients nutritional needs
• Patients often too ill to obtain energy
  nutrients by consuming foods
• Or illness may interfere with eating, digestion
  or absorption

3
Selecting a Feeding Route
4
Enteral Nutrition Support

• Wide selection of enteral formulas, designed to
  meet variety of medical nutritional needs
• May be used alone or in conjunction with other
  foods
• Many formulas can provide all of nutrient
  requirements if consumed in sufficient volume
• Classified according to macronutrient composition
• Preferred over intravenous feedings

Enteral nutrition requires intact normal GI
function
5
Types of Enteral Formulas

• Standard formula for patients who can digest
  absorb nutrients without difficulty contains
  protein carbohydrate sources
• Hydrolyzed formulas used for patients with
  compromised digestive or absorptive functions
  macronutrients are partially or fully broken down
  require little, if any, digestion before
  absorption
• Disease-specific formulas designed to meet
  nutrient needs of patients with particular
  disorders liver, kidney, lung diseases, glucose
  intolerance, metabolic stress
• Modular formulas contain only one or two
  macronutrients used to enhance other formulas

6
Enteral Nutrition in Medical Care

• Oral use
• Supplement diet when food consumption does not
  meet need
• Reliable source of nutrients energy
• Taste important consideration
• Tube feedings
• Used when patient cannot consume enough food or
  formula orally
• Feeding delivered directly to stomach or intestine

• Patients can drink enteral formulas when they are
  unable to consume enough food from a conventional
  diet

7
Enteral Nutrition in Medical Care (cont)

• Candidates for tube feedings
• Severe swallowing difficulties
• Little or no appetite for extended periods,
  especially if malnourished
• GI obstructions, impaired motility of the upper
  GI tract
• After intestinal resection, beginning enteral
  feedings
• Mentally incapacitated due to confusion,
  dementia, neurological disorders
• Individuals in coma
• Individuals with extremely high nutrient
  requirements
• Individuals on mechanical ventilators

8
Enteral Nutrition in Medical Care (cont)

• Feeding routes
• Selected on basis of medical condition, expected
  duration, potential complications of a particular
  route
• Main routes
• Transnasal (temporary)
• Nasogastric
• Nasoduodenal
• Nasojejunal
• Gastrostomy
• Jejunostomy

9
Enteral Nutrition in Medical Care (cont)

• Formula selected after assessment of the
  diagnosis, patients age, medical problems,
  nutritional status, ability to digest absorb
  nutrients
• Nutrition-related factors influencing formula
  selection
• Energy, protein fluid requirements
• Need for fiber modifications
• Individual tolerances (food allergies
  sensitivities)

10
Enteral Nutrition in Medical Care (cont)

• Administration of tube feedings
• Safe handling
• Open feeding system
• Closed feeding system
• Safety guidelines
• Review of procedure with patient family
• Verification of tube placement (Xray)
• Formula delivery
• Intermittent feedings (bulk over 20-40 min)
• Continuous feedings (pump)
• Bolus feeding (one or several shots)

• Open feeding system requires formula to be
  transferred from original packaging to feeding
  container
• Closed feeding system formula prepackaged in
  ready-to-use containers
• Intermittent feeding delivery of prescribed
  volume over 20-40 minutes
• Continuous feeding slow delivery at constant
  rate over 8-24 hour period
• Bolus feeding delivery of prescribed volume in
  less than 15 minutes

11
Enteral Nutrition in Medical Care (cont)

• Formula volume strength
• Procedures vary by institution
• Almost all patients can receive undiluted
  isotonic or hypertonic formulas
• Generally started slowly and volume gradually
  increased
• Rate amount of increase depend on patients
  tolerance
• Continuous feedings may be better tolerated than
  intermittent feedings
• Checking gastric residual volume (vol. of formula
  in stomach after fdg.)
• Volume of formula remaining in stomach from
  previous feeding
• Evaluate if gastric residual gt200 mL
• If tendency to retain persists, physician may
  consider intestinal feedings or drug therapy to
  stimulate gastric emptying

12
Enteral Nutrition in Medical Care (cont)

• Meeting water needs
• Adults require about 2000 mL of water daily
• Fluid intake may be restricted for patients with
  kidney, liver or heart disease
• Fluid intake may be increased with fever, high
  urine output, diarrhea, excessive sweating,
  severe vomiting, fistula drainage, high-output
  ostomies, blood loss, open wounds
• Standard formulas contain about 85 water (about
  850 mL/liter) nutrient-dense formulas contain
  about 69-72 water
• Meet fluid needs with additional water flushes

• Estimating fluid
• requirements
• Adults 30-40 mL/kg 30 mL/kg for older adults
• Children 50-60 mL/kg
• Infants 150 mL/kg

13
Enteral Nutrition in Medical Care (cont)

• Transition to table foods
• Volume of formula is tapered off as condition
  improves
• Gradual shift to oral diet
• Begin drinking same formula that is delivered by
  tube
• Oral intake should supply about 2/3 of nutrient
  needs before tube feedings discontinued

14
Enteral Nutrition in Medical Care (cont)

• Giving Medication through feeding tubes
• Potential for diet-drug interactions must be
  considered before administration
• Continuous feeding halted for approximately 15
  minutes before 15 minutes following medication
  delivery (longer for some medications)
• Type of medication may make tube administration
  impossiblerequire change to alternate route
• Generally best to administer medications by mouth
  whenever possible

15
Enteral Nutrition in Medical Care (cont)

• Complications of tube feedings
• Gastrointestinal problems nausea, diarrhea
• Mechanical problems related to tube feeding
  process
• Metabolic problems biochemical alterations
  nutrient deficiencies
• Many complications preventable with appropriate
  feeding route, formula delivery method
• Close attention to patients medical condition
  medication use is important (follow
  up/reassessment)
• Monitor weight, hydration status
• Verify lab test results

16
Parenteral Nutrition Support

• Indications
• Short-bowel syndrome
• Severe pancreatitis
• Malabsorption disorders
• Intestinal obstruction or fistula
• Severe burns or trauma
• Critical illnesses or wasting disorders
• Bone marrow transplant
• Malnourished with
• high risk for aspiration

• Indicated for patients who do not have
  functioning GI tract who are malnourished (or
  likely to become so)
• Used when enteral formulas cannot be used or
  intestinal function is inadequate
• Life-saving option for critically-ill persons
• Two main access sites central or peripheral vein

17
Venous Access

• Peripheral parenteral nutrition (PPN)
• Can only provide limited amounts of energy
  protein
• Peripheral veins can be damaged by overly
  concentrated solutions
• Limited to patients who do not have high nutrient
  needs or fluid restrictions
• Used most often for short-term nutrition support
  (7-10 days)
• Rotation of vein sites may be necessary

18
Venous Access (cont)

• Total parenteral nutrition (TPN)
• Can reliably meet complete nutrient requirements
• Provides nutrient-dense solutions for patients
  with high nutrient needs or fluid restrictions
• Preferred for long-term intravenous feedings
• Inserted directly into a large central vein

19
Parenteral Solutions

• Customized formulations to meet patients
  nutrient needs
• Highly individualized often recalculated on
  daily basis until patients condition stabilizes
• Contents
• Amino acids (both essential and non-essential for
  protein)
• Carbohydrates (dextrose)
• Lipid emulsions
• Fluid electrolytes
• Vitamins trace minerals

20
Administering Parenteral Nutrition

• Multidisciplinary nutrition support team of
  health care professionals
• Physicians
• Nurses
• Dietitians
• Pharmacist
• Potential complications related to venous line
  metabolic problems

21
Administering Parenteral Nutrition (cont)

• Administration procedures
• Insertion care of intravenous catheters
• Administration of parenteral solutions
• Continuous administration -24 hours/day
• Cyclic administration 10 to 16 hour periods
• Monitoring patient condition, nutritional status,
  complications
• Discontinuing of feedings-when GI function returns

22
Nutrition Support at Home

• Continuation of nutritional support (tube
  feedings or parenteral nutrition) after medical
  condition has stabilized
• Candidates for home nutrition support
• Long-term nutrition care required for chronic
  conditions
• Users intellectually capable of learning
  procedures, monitoring treatment managing
  complications
• Planning for home nutrition
• Involvement of users in decision making to ensure
  long-term compliance satisfaction
• Assessment evaluation of type of feeding,
  equipment, resources, ability to perform
  procedures

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Nutrition Support at Home (cont)

• Quality of life issues
• Lifestyle adjustments may cause struggle for
  patients families
• Economic impact
• Time other demands associated with treatment
• Physical difficulties, including disrupted sleep
• Social issues
• Life-sustaining therapy associated with serious
  complications

• Portable pumps convenient carrying cases allow
  people who require home nutrition support to move
  about freely

24
Nutrition in PracticeInborn Errors of Metabolism

• Inborn error of metabolism
• inherited trait, caused by genetic mutation
• Results in absence, deficiency or malfunction of
  a protein that has a critical metabolic role

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Nutrition in PracticeInborn Errors of Metabolism
(cont)

• Medical nutrition therapy is primary treatment
  for many inborn errors that involve nutrient
  metabolism
• Dietary intervention generally involves
  restriction of substances that cannot be
  metabolized or supplying substances that cannot
  be produced
• Dietary changes may improve outcomes
• Preventing accumulation of toxic metabolites
• Replacing deficient nutrients
• Providing a diet that supports normal growth
  development maintains health
• Some inborn errors may require treatment other
  than or in addition to dietary changes

26
Nutrition in PracticeInborn Errors of Metabolism
(cont)

• Phenylketonuria (PKU)
• Metabolic disorder affecting amino acid
  metabolism
• Missing or defective protein is liver enzyme that
  converts the essential amino acid phenylalanine
  to tyrosine
• Phenylalanine metabolites accumulate and damage
  developing nervous systemmost debilitating
  effect is on brain development
• Diagnosed within first few days following
  birthinfants routinely screened in all 50 states
• Treatment consists of lifelong diet restricting
  phenylalanine supplying tyrosine allowing
  blood levels of these amino acids to be
  maintained within safe ranges

27
Nutrition in PracticeInborn Errors of Metabolism
(cont)

• Managing PKU
• Central to PKU diet is enteral formula that is
  phenylalanine-free supplies energy, amino
  acids, vitamins minerals
• Formula requirements must be recalculated
  periodically to accommodate growing infants
  shifting needs for protein, phenylalanine,
  tyrosine energy
• Careful monitoring of foods containing
  phenylalanine
• Monitoring of growth rates nutrition status
• Parents children may need to develop creative
  ways to make diet enjoyable

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Nutrition in PracticeInborn Errors of Metabolism
(cont)

• Galactosemia
• Inborn error of carbohydrate metabolism
• Deficiency of enzyme needed to metabolize
  galactose
• Accumulation of galactose can result in damage to
  multiple tissues
• Reaction with severe vomiting jaundice within
  days of initial feeding of infant
• Serious liver damage may result, progressing to
  symptomatic cirrhosis
• Other complications kidney failure, cataracts,
  brain damage
• Delay in treatment can result in irreversible
  brain damage

29
Nutrition in PracticeInborn Errors of Metabolism
(cont)

• Managing galactosemia
• Main focus of diet is exclusion of milk milk
  products (elimination of galactose)
• Avoidance or restriction of other
  galactose-containing foods
• Organ meats
• Some legumes, fruits vegetables
• Food lists help patients to identify galactose
  content of common foods
• Complications may develop despite compliance with
  diet therapy