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Specialized Nutrition Support: Enteral

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Specialized Nutrition Support: Enteral & Parenteral Nutrition Chapter 16 Nutrition & Diet Therapy (7th Edition) – PowerPoint PPT presentation

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Title: 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

23
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

25
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

28
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
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