Title: Specialized Nutrition Support: Enteral
1Specialized Nutrition SupportEnteral
Parenteral Nutrition
2Need 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
3Selecting a Feeding Route
4Enteral 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
5Types 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
6Enteral 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
7Enteral 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
8Enteral 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
9Enteral 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)
10Enteral 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
11Enteral 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
12Enteral 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
13Enteral 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
14Enteral 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
15Enteral 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
16Parenteral 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
17Venous 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
18Venous 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
19Parenteral 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
20Administering Parenteral Nutrition
- Multidisciplinary nutrition support team of
health care professionals - Physicians
- Nurses
- Dietitians
- Pharmacist
- Potential complications related to venous line
metabolic problems
21Administering 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
22Nutrition 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
23Nutrition 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
24Nutrition 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
25Nutrition 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
26Nutrition 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
27Nutrition 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
28Nutrition 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
29Nutrition 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