© 2007 thomson - wadsworth chapter 15 enteral & parenteral nutrition support
TRANSCRIPT
© 2007 Thomson - Wadsworth
Nutrition Support
• Enteral• Means “within or by
means of the gastrointestinal tract.”
OralKnown as tube
feedingsPreferred route if
have adequate GI function
• ParenteralUses the veinsPersons with
inadequate GI function
© 2007 Thomson - Wadsworth
If you choose enteral nutrition support…
• Must have functional GI tractBowel sounds
• Can be used alone or as a supplement
• Variety of kinds of formulas
• TypesStandard (1.0-1.2cal/ml)
• Tolerated by most patients
Hydrolyzed• Partially or fully broken down• Persons with compromised GI
functioning
High calorie Disease-specificModular
• contain 1-2 macronutrients
© 2007 Thomson - Wadsworth
Enteral Nutrition Support
• Provide Pro, CHO and Fat
• Nutrient Density Protein = 8-29% of
total kcaloriesStandard formulas
• Carbohydrates = 40-50% total kcalories
• Fat = 30-45% total kcalories
• Energy Density0.5-2.0 kcalories per mLStandard formulas
• 1.0-1.2 kcalories per mL• Patients with average
fluid requirements
Formulas with higher energy density
• Smaller amount of fluid• Good for fluid restrictions
© 2007 Thomson - Wadsworth
Feeding Routes
• Tube feeding less than 4 weeks Nasogastric
• Postplorically Nasoduodenal Nasojejunal These tubes are weighted
or non-weighted with stylets to guide placement
• Orogastric Mouth to stomach Good for vent patients
• Tube feeding more than 4 weeks
• Enterostomy Gastrostomy Jejunostomy
• Gastric feedings are the preferred route Easily tolerated & less
complicated Not good for patients at
risk for aspiration
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Osmolality
• A solution’s tendency to shift from one fluid compartment to another across a semipermeable membrane
• Range: 300-700 milliosmoles per kilogram • Isotonic: osmolality similar to blood• Hypertonic: osmolality greater than blood
© 2007 Thomson - Wadsworth
Enteral Nutrition in Medical Care
• Preferred over parenteralHelps maintain gutFewer
complicationsLess costly
• Oral preferred over tube feedingsLess stressLess complicationsLess costly
• Can fully meet nutrient needs
• Good for weak & debilitated patients
• Nurses help patients find appealing flavors
© 2007 Thomson - Wadsworth
Candidates for Tube Feedings
• Severe swallowing problems
• Little or no appetite• GI obstructions,
impaired GI motility• Intestinal
resections
• Mentally incapacitated
• Coma • Extremely high
nutrient requirements
• Mechanical ventilators
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Feeding Tubes
• Soft & flexible• Variety of lengths & diameters• Outer diameter measured in French units
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Formula Selection
• Need to assessAgeMedical problemsNutritional statusAbility to digest &
absorb nutrients
• Choose the oneWith the lowest risk
of complicationsLowest cost
• Nutrition-related factorsEnergy, protein, &
fluid requirementsNeed for fiber
modification Individual tolerances
(food allergies & sensitivities)
What Formula?
• Factors to considerGI functionCalorie and protein
densityAbility to meet needsType of
• Protein, fat, CHO• Fiber
ElectrolytesFluidViscosityOsmolality
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
Administration of Tube Feedings
• Safe handling Clean equipment Clean hands
• Open system Formula needs to be
transferred from original packaging to feeding container
• Closed system Formula is prepackaged
• Safety guidelines Clean can opener & lid Refrigerate unused portions
in clean, closed containers Discard unlabeled or
unused within 24 hours Open system; hang no
longer than 8-12 hour supply
Closed system; hang no longer than 24-48 hour supply
© 2007 Thomson - Wadsworth
Tube Feeding
• Initiating tube feeding Discuss with patient
& family Check initial
placement with X-ray Monitor its position
throughout the day: can check fluid pH
• Formula delivery Intermittent
• Gastric, 2500-400 mL over 20-40 minutes
• Risk of aspiration Bolus
• Gastric • Delivery of <500mL every 3-4
hours Continuous
• Slowly at constant rate• 8-24 hours• Noctural
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Administering the Feeding
• Formula volume & strengthVaries among
institutionsHypertonic fluids
usually started slowly & volume gradually increased
Assess patient tolerance
• Checking gastric residualsWithdraw contents
through feeding tube with syringe
Intermittent before each feeding
Continuous every 4-6 hrs
© 2007 Thomson - Wadsworth
Tube Feedings
• Supplemental waterFormulas are 69-
85% waterMore water comes
from flushes via feeding tubes
• Flush before & after each bolus or intermittent feeding
• Flush every 4 hours for continuous
• Count as intake
• Transition to table foodsGradually shift to
oral dietOral needs to be
2/3 of nutrient intake before discontinuing the tube
© 2007 Thomson - Wadsworth
Tube Feedings
• Delivering medicationsNeed to consider
diet-drug interactionsMedications can clog
tubesContinuous: stop
feeding 15 minutes before & after medication administration
• ComplicationsNausea & diarrheaMechanical problemsMetabolic problems
• Monitor patient’sWeightHydration statusLab test results
© 2007 Thomson - Wadsworth
Indications for Parenteral Nutrition
• Short bowel syndrome
• Severe pancreatitis
• Malabsorption disorders
• Intestinal obstructions or fistulas
• Severe burns or trauma
• Critical illnesses or wasting disorders
• Bone marrow transplants
• Malnourished & high risk for aspiration
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Venous Access
• Peripheral Parenteral Nutrition (PPN)Peripheral veinsShort-term support Patients with average
nutrient needs & no fluid restrictions
Veins can be damaged
• Need solutions under 800-900 mOsm
• Total Parental Nutrition (TPN)Larger, central
veinsLong-term supportPatients with high
nutrient needs or fluid restrictions
© 2007 Thomson - Wadsworth
Parenteral Solutions
• Contain amino acidsAll essential plus
combinations of non-essential
• Contain carbohydratesDextrose, 3.4
kcalories/gram2.5-70% concentrations>10% only for TPN
• Contain lipidsSignificant source of
energy10, 20% solutionsOften provided daily &
= 20-30% total kcalories
Decreases risk of hyperglycemia from dextrose
© 2007 Thomson - Wadsworth
Parenteral Solutions
• FluidNeed 1500-2500
mL/day for adults
• Contain electrolytes Sodium, potassium,
chloride, calcium, magnesium, & phosphorus
Expressed in milliequivalents (mEq)
• Contain vitaminsAll water-soluble plus A,
D, & EK must be added
separately
• Contain trace mineralsZinc, copper, chromium,
selenium, & manganese Iron is excluded
© 2007 Thomson - Wadsworth
Types of Parenteral Solutions
• Total Nutrient Admixture (TNA)3-in-1 solutionAlso called “all-in-one” solutionContains dextrose, amino acids, & lipids
• 2-in-1 solutionDextrose & amino acidsLipids administered separately to
provide essential fatty acids
© 2007 Thomson - Wadsworth
Administering Parenteral Nutrition
• Team effort Physicians Dietitians Pharmacists Nurses: provide direct
care
• IV catheters Nurse can place in
peripheral veins Physician must place
in central veins
• Problems DislodgingAir embolismClotting Phlebitis Infection
• Must use aseptic technique
Parenteral Nutrition Complications
• Mechanical complications• Infection and sepsis• Metabolic Complications• Gastrointestinal Complications
© 2007 Thomson - Wadsworth
© 2007 Thomson - Wadsworth
Parenteral Solutions
• AdministeringContinuous
• Critically ill• Malnourished
Cyclic • 10-16 hours• Often provided at
night
Check tubing & solution daily for contamination
• DiscontinuingWhen 2/3-3/4 of
nutrient needs are provided by enteral feedings, IV can be discontinued
Clear liquids Small enteral
feedings to determine tolerance
© 2007 Thomson - Wadsworth
Managing Metabolic Complications
• Hyperglycemia Patients who are glucose
intolerant or in severe metabolic stress
Provide insulin with feedings or decrease dextrose
• Hypoglycemia When feedings are
interrupted or discontinued
Taper slowly
• Hypertriglyceridemia Critically ill can’t tolerate
lipid infusions Impaired lipid clearance
• Refeeding syndrome Re-feed slowly Life-threatening
• Abnormal liver function Long-term, can lead to
liver failure Cause unclear
© 2007 Thomson - Wadsworth
Managing Metabolic Problems
• Gallbladder diseaseParenteral for more
than 4 weeksSludge builds up,
leading to gallstonesCholecystokinin
injections or remove gallbladder
• Metabolic bone diseaseLong-term
parenteral lowers bone density
Alterations in calcium, phosphorus, & vitamin D metabolism
© 2007 Thomson - Wadsworth
Nutrition Support at Home
• CandidatesEnteral
• Head & neck cancers• Neurological
impairments affecting swallowing
Parenteral• Portion of small
intestine removed• Intestinal obstructions• Malabsorption
conditions
• Planning EnteralNasal tubes or
enterostomies Investigate cost &
availability
• Planning ParenteralSterile & aseptically
preparedCyclic best
© 2007 Thomson - Wadsworth
Quality of Life Issues
• Economic impact• Time-consuming• Inconvenient• Disturbed sleep• Activities & work
must be planned around feedings
• Social issues Inability to
consume meals with friends & family
Inability to go to restaurants & social events
Fear, anxiety & depression
© 2007 Thomson - Wadsworth
Ethical Principles & Health Care
• Patient autonomy The right to make own
health care decisions
• Disclosure Fully informed of
treatment’s risks & benefits
• Decision-making capacity Mental capacity to
make appropriate health care decisions
• Treatment benefits (beneficence) should outweigh harm (maleficence)
• Distributive justice Would care given to one
patient unfairly limit the care of other patients?
© 2007 Thomson - Wadsworth
Life-Sustaining Treatments
• Nutrition support & hydration
• Cardiopulmonary resuscitation (CPR)
• Defibrillation• Mechanical ventilation• Dialysis
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Legal Documents for End of Life Care
• Living will, medical directive Written statement
specifying medical procedures desired or not desired
• Advanced directive Written or oral
instruction regarding one’s preferences for medical treatment
• Durable power of attorney Another person is
appointed to make health care decisions in the event of incapacitation
• Do-not-resuscitate (DNR) Order to withhold CPR in
the event of a cardiac arrest