feeding patients

FEEDING PATIENTS THERAPEUTIC DIETS

By ZIA IMRAN 2015 year 1

© 2007 Thomson - Wadsworth

Feeding Patients

• Enteral • Means “within or by means of the

gastrointestinal tract.”

Oral

Known as tube feedings

Preferred route if have adequate GI function

• Parenteral

Uses the veins

Persons with inadequate GI function

© 2007 Thomson - Wadsworth

• Enteral Nutrition:

Enteral nutrition: The delivery of nutrients by tube into the gastrointestinal tract, commonly known as tube feeding.

Parenteral Nutrition:

Parenteral nutrition: The delivery of nutrients by vein.

Tube feeding is used for patients:

Who have Chewing & Swallowing

problem

Have prolonged Lack

Of appetite

have an obstruction,fistula,or Altered motility in upper GIT

Are in coma

has a high nutrient requirement

TUBE FEEDINGS ARE CONTRAINDICATED:

When GIT tract is non functional as in gastric or intestinal obstruction

Paralytic ileus(obsruction of the intestines due to paralysis of the intestinal muscles)

Intractable vomiting and diarrhea(not easily controlled or manageable)

Feeding Routes:

TRAN NASAL TUBES:(T.F less than 4 weeks) of which NG is the most common and generally used for T.F of relatively short duration

OSTOMY FEEDINGS: (T.F more than 4 weeks) are preferred for permanent or long term feedings.E.G;gastrostomy ,jejunostomy

CHARACTERISTICS FOR FORMULA FEEDING:

A satisfactory formula feeding must be:

Nutritionally adequate

Well tolerated by the patient so that vomiting is not be induced

Easily digested with no unfavorable reactions such as distention,diarrhea,or constipation.

Easily prepared and inexpensive

© 2007 Thomson - Wadsworth

Formula Selection

• Need to assess

– Age

– Medical problems

– Nutritional status

– Ability to digest & absorb nutrients

• Choose the one

– With the lowest risk of complications

– Lowest cost

• Nutrition-related factors

– Energy, protein, & fluid requirements

– Need for fiber modification

– Individual tolerances (food allergies & sensitivities)

Types of Formulas:

The two major types of formula are available.

Standard

&

Hydrolyzed

Standard Formulas:(also known as

polymeric formulas: solution that requires intact nutrients whole proteins and long chain triglycerides) are intended for patients who have normal digestive and absorptive capacity.

Standard tube feeding formulas come in wide variety such as isotonic,hypercaloric,fiber containing products.

Isotonic formulas: have the same concentration of solute as another solution.

Hypertonic formulas: have greater concentration of solute than another solution.

Hyper caloric formulas: have more than 1kcal/ml(1.5-2.0Kcal/ml) than another solution.

Fiber containing formulas: are low osmolality and used for patients with abnormal bowel regulation.

Hydrolyzed Formulas::

Partially hydrolyzed formulas contain proteins that are partially digested into small peptides.

Proteins in completely hydrolyzed formulas, referred to as “elemental formulas", is in its simplest form; free amino acids.

Hydrolyzed formulas are intended for patients with impaired digestion or absorption such as inflammatory bowel disease, pancreatic disorders.

Modular Formulas:

are not nutritionally complete by themselves. They are added to foods or other enteral products to change composition when nutrition needs cannot otherwise be met.

SUMMARY – TYPES OF NUTRITIONAL FORMULAS

FORMULA TYPE CONTENTS SELECTION

MODULAR SUPPLEMENTS

(3.8-4.0 kcal/ml)

POLYMERIC(intact proteins)

1-2kcal/ml

ELEMENTAL(pre-digested or

hydrolyzed)1-1.3kcal/ml

DISEASE SPECIFIC

One nutrient source

Not nutritionally complete by

themselves.

Considered to be nutrient dense

without increasing volume.

Contains intact proteins of high

biological value, complex

CHO,fats,vitamins,minerals and

trace elements.

Provides nutrients in pre digested

form, making their transport and

absorption easier in the body.

PROVIDES FORMULATION

SPECIFIC TO METABOLIC

REQUIREMENTS.

CHO-Moducal,Nutrisource

CHO.

lipids- MCT,Microlipid

Protein-Promod,cPasec

Ensure,Sustacal,

Resource.

Vital,Vivonex.

Liver—Hepatic-Aid

Pulmonary__Pulmocare

Renal---Travasob,Renal

A comparison B/W standard and hydrolyzed Enteral formulas

Standard Hydrolyzed Calories /ml Most are 1.0-1.2 1.0-1.5

Sources of protein Casein hydrolysates Hydrolyzed

casein,whey or soy

protein:amino acids

carbohydrates Maltodextrin,sucrose

,corn syrup solids

Maltodextrin,modified

corn starch

Fat Vegetable oil Vegetable oil,MCT

Osmolality Many are isotonic Most are hypertonic

Residue Most are low Virtually residue free

Fiber Fiber-enriched

formulas are available

Fiber-free

Cost Relatively inexpensive Relatively expensive

• HOME BLEND FORMULAS

• Occasionally patient requests or is required to prepare tube feeding at home. Though this is possible and does have some benefits, there are some significant points to be consider when home blend formulas are prescribe to the patient.

• The table below will show the advantages and disadvantages of home blend formulas.

• Advantages of home blenderized formulas:

• Family can take an active part in food preparation for patient

• Less costly

• Increased amount of fiber can be provided

• Sense of " being different " is lessened since the patient can enjoy the same table food as his or her family

• Manipulation of individual nutrients is easier in blenderI zed feedings than with commercial products

• Unpleasant taste Is less likely to occur

• Disadvantages of home blenderized formulas

• Blenderized feeding require more time and energy to prepare than commercial products

• Special equipment is needed i.e. blender or food processor, measuring utensils, access to refrigeration etc

•

• Special care must be taken to liquefy the contents of the blender completely, as food particles can clog the feeding tube

•

• Feeding must be prepared daily

• Daily ingredient selection should be carefully made to ensure nutrition adequacy of diet.

• May need vitamin and mineral supplementation

• Extra amount of blender zed feed must be kept refrigerated and must slightly warmed before feeding.

• Higher incidence of bacterial contamination may occur

•

• Blenderized feeding are difficult to make if the patient is away from home

DELIVERY METHODS:

Intermittent T.F

Bolus Feedings

Continuous Drip Method

Intermittent T.F giving a 4-6 hr volume of feeding solution over 20-30 minutes. The number of feedings given / day depends on the total volume of feeding needed.

Bolus Feeding: giving a 4-6 hr volume of feeding solution within a few minutes. They are used only for feedings into the stomach.

Continuous Drip Method: delivery of T.F on an ongoing basis. A continuous feeding is always recommended for formulas delivered directly into the small intestine.

MOST COMMON TUBE FEEDING PROBLEM,RATIONALE & CORRECTIVE ACTION:

Problems Rationale Corrective action

DIARRHEA Infection Microbial contamination of formula. Malabsorption Bolus feeding, volume over load, rapid administration. Hyperosmolar formulas(OSMOLALITY)** Medications

Switch to isotonic formula & feed at slow rate. Change to low fat, lactose free or elemental formula. Decrease bolus volume and increase frequency of feeding. Reduce rate and increase gradually, change formula or change to isotonic products. Evaluate medications as primary cause.

Problem Cause Corrective action

CLOGGED TUBE

Feeding heated formulas. Improper cleaning of tube.

Do not heat formulas. Flush the tube before and after each infusion. High viscosity formulas(blenderized, or commercial formulas that provide 1.5-2 Kcal/ml)should be infused by pump & possibly through a large bore feeding tube to prevent clogging.

© 2007 Thomson - Wadsworth

Osmolality **

• A solution’s tendency to shift from one fluid compartment to another across a semi permeable membrane

• In Enteral formulas,osmolaity is determined by the concentration of sugars, amino acids and electrolytes

• Range: 300-700 milliosmoles per kilogram • Isotonic: osmolality similar to blood(300mOsm/kg) • Hypertonic: osmolality greater than

blood(>300mOsm/kg) • Hydrolyzed formulas: are higher in osmolality than

standard formulas.

ADMINISTRATION OF MEDICATION TO THE TUBE FED PATIENTS:

• If possible, administer drugs in liquid form • Administer crushed tablet only when no other

alternative is available • Crush the tablet to a fine powder and mix with

water. • Administer each drug separately. • Flush the tube with at least 30ml water before

giving the medicine. • If the medication is ordered to be added to the

feeding observe the feeding after addition for any reaction or precipitation.

Parenteral Nutrition Support

© 2007 Thomson - Wadsworth

© 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

© 2007 Thomson - Wadsworth

Venous Access

• Peripheral Parenteral Nutrition (PPN)

– Peripheral veins

– Short-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 veins

– Long-term support

– Patients with high nutrient needs or fluid restrictions

© 2007 Thomson - Wadsworth

Parenteral Solutions

• Contain amino acids

– All essential plus combinations of non-essential

• Contain carbohydrates

– Dextrose, 3.4 kcalories/gram

– 2.5-70% concentrations

– >10% only for TPN

• Contain lipids – Significant source of energy

– 10, 20% solutions

– Often provided daily & = 20-30% total kcalories

– Decreases risk of hyperglycemia from dextrose

© 2007 Thomson - Wadsworth

Parenteral Solutions

• Fluid

– Need 1500-2500 mL/day for adults

• Contain electrolytes

– Sodium, potassium, chloride, calcium, magnesium, & phosphorus

– Expressed in milliequivalents (mEq)

• Contain vitamins

– All water-soluble plus A, D, & E

– K must be added separately

• Contain trace minerals

– Zinc, copper, chromium, selenium, & manganese

– Iron is excluded

© 2007 Thomson - Wadsworth

Types of Parenteral Solutions

• Total Nutrient Admixture (TNA)

– 3-in-1 solution

– Also called “all-in-one” solution

– Contains dextrose, amino acids, & lipids

• 2-in-1 solution

– Dextrose & amino acids

– Lipids administered separately to provide essential fatty acids

© 2007 Thomson - Wadsworth

Parenteral Solutions

• Administering

– Continuous • Critically ill

• Malnourished

– Cyclic • 10-16 hours

• Often provided at night

– Check tubing & solution daily for contamination

• Discontinuing

– When 2/3-3/4 of nutrient needs are provided by enteral feedings, IV can be discontinued

– Clear liquids

– Small enteral feedings to determine tolerance

THERAPEUTIC DIETS

Altered Consistency Diets.

1. Clear liquid diet

2. Full liquid diet

3. Pureed diet

4. Dysphagia diet

5. Soft diet

• CLEAR LIQUID DIET:

o Provides adequate water/fluid,500—1000Kcal of simple sugars, electrolytes and is fiber free.

o It requires minimal digestion, as there is no residue of fiber.

o It is recommended for short term use(3-5days)can be used both before and after surgery or diagnostic procedures and during acute stages of illness.

o It consists of see through foods that are liquid at body temperature----jelly, black tea, black coffee, broth.

CLEAR LIQUID FOODS

FULL LIQUID FOODS

SOFT DIET FOODS

BLENDERIZED FOODS

FULL LIQUID DIET: o Provides water,calories,protein,vitamins and

minerals, and dairy products(contains lactose)and is considered to be low in residue.

o It may be indicated for some clients who have difficulty chewing or swallowing.

o It can be considered to be a transition diet(moving from one diet to another as the clients clinical status improves).

o It consists of all foods found in clear liquid diet, plus milk,puddings,custards,icecreams,soups,yogurts and all prepared liquid formulas.

o Clients who are lactose intolerant may require lactose free supplements to prevent clinical symptoms.

• DYSPHAGIA DIET: o Consists of thickened liquids provided to clients who have

swallowing problems and are at risk for aspiration(such as those post-CVA).

o Thickening agents can be added to foods to maximize texture

and help facilitate the swallowing process.

o Stringy ,raw,dry,and fried foods are not allowed on this type of diet due to potential aspiration.

o Foods such as popcorn,nuts,and small candies, should be avoided due to risk of aspiration.

o Positioning of the client to at least 30-40 degrees or higher and monitoring of feedings are critical during

meals in order to decrease risk of aspiration and evaluate clients attempts at eating.

SOFT DIET:

o This food includes food items that contain small amounts of seasoning and moderate fiber content but are easy to chew,digest,and absorb.

o Foods that are highly seasoned,fried,high in fiber,nuts,coconuts,and foods that contain seeds are not included in the diet as they could cause GI symptom upset.

o It can be used as a progressive or transition diet and is a modification of a regular diet.

RESTRICTIVE/MODIFIED DIETS 1. Carbohydrate controlled diets(e.g;in Diabetes). 2. Gastric-bypass diet(gasric bypass in obesity) 3. Low residue diet(diarrhea) 4. Fat controlled diet(pancreatitis,gall bladder

disease) 5. Protein controlled diet(renal failure,Liver

cirrhosis) 6. Food allergy diet(in infants first few months) 7. Purine controlled diet(gout) 8. Sodium controlled diet(cardiovascular diseases) 9. Low bacteria diet(bone marrow transplant).

FOOD ALLERGY DIETS

Gluten Restricted Diet: is used for clients who have celiac disease(malabsorption syndrome) and omits wheat,rye,barley,and oats. Gluten from rice and potatoes has no harmful effects.

Lactose Restricted Diet: is used for clients who have lactose intolerance due to lactase-enzyme deficiency. Foods that are included are hard cheese rather than soft cheese because hard cheese is lower in lactose due to aging process.

Yogurt can be included in the diet because of its bacterial action.

Special milk products are available for lactose intolerant client.

• SUPPLEMENTAL/ENHANCED DIET

HIGH FIBER DIET:A high fiber diet is used to promote regularity, and maintain normal bowel function and elimination patterns.

HIGH POTASSIUM diet: is used for patients who have potassium losses due to diuretic therapy.

HIGH CALCIUM DIET: diet is indicated for clients who have disease states that promote Ca++ loss leading to demineralization (osteoporosis) .

HIGH PROTEIN DIET: is indicated for athletes, and patients suffering from nephrotic syndrome(renal disorder).

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