Enteral Nutrition

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Enteral Nutrition
Lynn Thomas, DrPH, RD
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Basic Diet Orders

• NPO
• Nothing by mouth
• NPO x meds
• Sips
• Clear Liquids - ginger ale, gelatins, Popsicles,
  strained juices, sherbet, slushes, tea or decaf
  coffee

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Diet Orders

• Full Liquids - milk, cream soups, milk shakes,
  pudding, custard, everything on clear liquids
• Soft diet - mashed potatoes, pasta, casseroles,
  cooked vegetables, canned fruits, liquids

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Types of Diets

• Pureed
• Dysphagia
• Electrolyte or fluid restriction

• High fiber or low fiber
• Low CHOL or low fat

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Supplements

• Milk based or lactose free.
• Clear liquid protein boosters.

Oral supplements to boost kcal and protein.
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Diet Orders

• Diet orders written by MD.
• Nurses per verbal orders.
• RD per verbal orders.
• Standard diet varies in each hospital
• Providence AHA Heart Healthy Diet
• VA average male 2400 kcal/85 g protein

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Doctors Orders

• Diet orders written with admission orders
• DX/Condition
• Diet Orders including NPO
• Tests/Labs
• Meds/IV Fluids
• Consults
• Separate orders for additional changes

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Tube Identification

• Nasogastric
• Nasoduodenal
• Nasojejunal
• Oral placement
• Should be small
• in diameter and soft

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Tube Identification

• Surgical Esophagostomy
• Surgical or Percutaneous endoscopic gastrostomy
  tube
• Surgical or Percutaneous endoscopic jejunostomy
  tube

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Delivery Methods

• Continuous Drip
• 24 hours or cyclic
• Intermittent Delivery
• over 24 hours
• no night feedings at home
• Bolus Delivery
• only for the alert and oriented

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Delivery Formulas

• Intermittent into the gut
• Continuous into small bowel.
• Isotonic formulas best tolerated in small bowel.
• Hypertonic formulas into gut. Dilute into small
  bowel.

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Osmolality

• Measure of concentration of molecular and ionic
  particles in a solution.
• Isotonic formulas 300 mOsm/kg
• same as blood serum
• 300 400 well tolerated
• Hypertonic Formulas
• 400 mOsm/kg

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How much Formula?

• Energy needs- start with 25 -35 kcal/kg actual or
  dry weight. Order metabolic cart analysis if
  available.
• Protein needs- start with 1.0-1.2 g/kg and
  increase or decrease as needed. Lower in
  encephalopathy and acute renal. Higher in stress
  and trauma.

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Other Common Restrictions

• Fluid restriction is generally most limiting in
  product selection.
• All are low sodium.
• Potassium restriction common with renal.
  Generally 2-3 g/day or 55-80 mEq.
• fat and kind of fat varies.

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Order Writing

• Intermittent Delivery
• 1 can Ensure Plus with 240 cc H20 q4 hours.

• Continuous Drip
• FS Osmolite HN _at_ 40 ml/hr with 100 cc H20 q6
  hours as tube flush.

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Supplemental Water

• Dont forget to water your enteral feeding
  patients!
• Tubes need to be flushed on a schedule before
  and after meds before and after feedings.

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Do the Math- 60 kg patient

• Want to feed 30 kcal/kg
• 60 kg x 30 1800
  kcal/day
• 1 kcal/ml formula
• 1800 ml to meet needs
• Pump FS
• 1800/24 hours 75 ml/hr
• FS Isocal_at_75ml/hr with 100 ml H20 q6 hours

• 1.5 kcal/ml formula
• 1800 kcal/1.5 1200 ml to meet needs
• Intermittent
• Divide volume by number of feedings
• 240 ml (can) with
• 240 ccs H20 q 4 hours, omit 2 am feeding

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Medication Delivery

• Liquid form when available
• Dilute thick medications
• Crush pills, etc., and mix with water to form a
  slurry
• Order tubes flushed with water before and after
  giving meds
• Medications are not put in the in the feeding

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Parenteral Nutrition
Lynn Thomas, DrPH, RD
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Indications

• Patients with an inability to absorb nutrients
  via the gastrointestinal tract.
• Patients whose nutrient needs cannot be met with
  enteral feedings within 7 to 10 days.
• Patients with severe malnutrition or catabolism
  where the GI tract is not usable within 3-5 days.

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Contraindications

• Patients with a functional and usable GI tract
  capable of absorption.
• Less than 5 days of treatment anticipated.
• When prognosis does not warrant aggressive
  nutrition or when not wanted by patient or family.

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Central sites Internal
jugular Subclavian vein Femoral vein
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15- 30
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Limitations

• Determine any special requirements such as higher
  fat and lower carbohydrate.
• Check for additional electrolyte adjustments.
• Decide if a fluid restriction is necessary.

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Pharmacy Label

• Dextrose 70 450 ml
• Amino Acids 10 900 ml
• Fat emulsion 20 225 ml
• MVI-12 10 ml Trace Elements 3 ml
• Hyperlyte 45 ml sterile H20 167 ml
• 75 ml/hr
• Final Conc Dex 17.5 and AA 5

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Another Example

• Volume of 3000 ml
• Run at 125 ml/hr
• Dextrose 7, AA 3
• 115 ml 20 lipids/liter
• Standard lytes, MVI TE
• 40 CHO, 20 AA, 40 Fat

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Keep in Mind

• 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.