Chapter 15 Enteral and Parenteral Nutrition Support

Enteral and
Parenteral
Nutrition
Support
1515
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© Cengage Learning 2017
Introduction
• Nutrient delivery for patients too sick to
consume a normal diet
• Enteral nutrition
– Tube feedings directly to the stomach or small
intestine
• Parenteral nutrition
– Nutrients provided intravenously
• When possible, why is enteral preferred
over parenteral?

Enteral Nutrition
• Oral supplements
– Primary nutrition problem: poor appetite
– Adequate nutrition by this means avoids
stress, complications, and expense of tube
feedings
– Box 15-2 provides tips for improving intakes
with oral supplements

Enteral Nutrition (cont’d.)
• Candidates for tube feedings
– Severe swallowing disorders
– Impaired motility in the upper GI tract
– GI obstructions and fistulas that can be
bypassed with a feeding tube
– Certain types of intestinal surgeries
– Little or no appetite for extended periods

• Candidates for tube feedings
– Extremely high nutrient requirements
– Mechanical ventilation
– Mental incapacitation due to confusion,
neurological disorders, or coma
– What conditions are contraindications for tube
feeding?

• Tube feeding routes (Box 15-3)
– Factors in selecting feeding route
• Patient’s medical condition
• Expected duration of tube feeding
• Potential complications of a particular route

Tube Feeding Routes

Enteral Nutrition:
Tube Feeding Routes (cont’d.)
• Gastrointestinal access
– Tube feeding for <4 weeks
• Nasogastric or nasointestinal route
• Feeding tube passed into the GI tract via the nose
– Feeding tube tip placement
• Nasogastric (stomach)
• Nasoduodenal or nasojejunal (small intestine)

Enteral Nutrition:
• Gastrointestinal access
– Infants: orogastric placement sometimes
preferred over transnasal routes
– Direct route to stomach or intestine
• Tube feeding >4 weeks
• Inaccessible nasointestinal route
• Types of direct routes: enterostomy, gastrostomy,
or jejunostomy

Enteral Nutrition:
• Selecting a feeding route (Table 15-1)
– Based on duration
• Transnasal access for <4 weeks and
enterostomies for longer periods
– Gastric feedings (nasogastric and
gastrostomy routes)
• Preferred whenever possible
• Avoided in patients at high risk of aspiration

Enteral Nutrition:
• Feeding tubes
– Soft, flexible materials
– Tube selection factors
• Patient’s age and size, the feeding route, and the
formula’s viscosity
– Outer diameter measured in French units
• 1 French unit = 1/3 mm; 12 French = 4 mm
– Double-lumen tubes
• Intestinal feedings and gastric decompression

• Enteral formulas (Appendix G)
– Types of enteral formulas
• Standard formulas: patient can digest and absorb
nutrients without difficulty
• Elemental formulas: patients who have
compromised digestive or absorptive functions
• Specialized formulas: meet the specific nutrient
needs of patients with particular illnesses
• Modular formulas: patients who require specific
nutrient combinations to treat their illnesses

Enteral Nutrition: Enteral Formulas
(cont’d.)
• Macronutrient composition
– Protein: 12% to 20% of total kcalories
– Carbohydrate: 30% to 60% of kcalories
– Fat: 15% to 30% of kcalories
• Energy density
– 1.0 to 2.0 kcalories per milliliter of fluid
• Fiber content
– Formulas with or without fiber

(cont’d.)
• Osmolality: moles of osmotically active
solutes (or osmoles) per kg of solvent
– Isotonic formula: osmolality similar to blood
serum
– Hypertonic formula: osmolality greater than
blood serum
– Most enteral formulas: 300 to 700
milliosmoles per kilogram

(cont’d.)
• Formula selection (Figure 15-3)
– GI function
– Nutrient and energy needs
– Fluid requirements
– Need for fiber modifications
– Individual tolerances (food allergies and
sensitivities)

(cont’d.)
• Safe handling
– Facility-specific protocols
– Open feeding system vs. closed feeding
system
• Formula safety guidelines
– What steps can reduce the risk of formula
contamination when using open feeding
systems?

• Administration of tube feedings
– Preparing for tube feedings
• Fully discuss the procedure with the patient and
family members
• Box 15-5 offers tips for talking to patients
• Use X-rays to verify tube placement before
initiating feeding
• Elevate patient’s upper body (30- to 45-degrees,
during + 30-60 min after) to reduce aspiration risk

Enteral Nutrition:
Administration of Tube Feedings (cont’d.)
• Formula delivery methods
– Intermittent feedings: 250-400 mL formula
delivered over 30-45 min (usually to stomach)
– Bolus feedings: 250-500 mL over 5-15 min
– Continuous feedings: slow, constant delivery
over 8-24 hours (usually to intestine)
– Box 15-6 describes how to plan a tube
feeding schedule

Enteral Nutrition:
• Initiating and advancing tube feedings
– Formulas typically provided full-strength
– Intermittent feedings: 60-120 mL at the initial
feeding; increase by 60-120 mL at each
feeding until reaching the goal volume
– Continuous feedings: start at rates of 40-60
mL/hour; raise by 20 mL/hour every 8-12
hours until reaching the goal rate

Enteral Nutrition:
• Initiating and advancing tube feedings
– If the patient cannot tolerate an increased
delivery rate, feeding rate slowed until the
person adapts
– Slower delivery rates better tolerated: critically
ill patients; concentrated formulas used;
patients who have undergone an extended
period of bowel rest

Enteral Nutrition:
• Checking the gastric residual volume
– Volume of formula and GI secretions
remaining in the stomach after feeding
• Meeting water needs
– Adult requirements: 30-40 mL/kg/day
– Enteral formulas: 70% to 85% water
(700 to 850 mL of water per liter)
– Water flushes contribute to fluid intake

• Medication delivery during tube feedings
– Medications and continuous feedings
• Why are continuous feedings stopped prior to and
after medication administration?
– Diarrhea
• Medications are a major cause
• Dilution of hypertonic medications may be helpful
– Box 15-8 provides further details

• Tube feeding complications (Table 15-2)
– GI, mechanical, and metabolic problems
– Many complications preventable by
appropriate selections:
• Feeding route
• Formula
• Delivery method

• Transition to table foods
– Transition steps depend on
• Patient’s medical condition
• Type of feeding the patient is receiving
– Tube feeding discontinued when oral intake
supplies ~2/3 of estimated nutrient needs

Parenteral Nutrition
• Candidates for parenteral nutrition
– Intractable vomiting or diarrhea
– Severe GI bleeding
– Intestinal obstructions or fistulas
– Paralytic ileus (intestinal paralysis)
– Short bowel syndrome
– Bone marrow transplants
– Severe malnutrition and intolerance to enteral
nutrition

Parenteral Nutrition (cont’d.)
• Venous access
– Peripheral parenteral nutrition (PPN)
• Nutrients via peripheral veins only
• What can be done to prevent phlebitis?
• Candidates for PPN
– Require short-term nutrition support
– Do not have high nutrient needs or fluid restrictions

• Venous access
– Total parenteral nutrition (TPN)
• Nutrients delivered via central veins
• Preferred for cases requiring nutrient-dense
solutions or long-term parenteral nutrition
• Central venous catheter placement

• Parenteral solutions
– Often prepared by pharmacies located within
health care institutions (Figure 15-11)
• Customize the solutions
• Solutions have a limited shelf life
– Amino acids
• Contain essential + nonessential amino acids
• Concentrations: 3% to 20%

Parenteral Nutrition:
Parenteral Solutions (cont’d.)
• Carbohydrate
– Main source of energy: glucose (dextrose
monohydrate, 3.4 kcal/g)
– Concentration examples:
• D5W (5% dextrose in water)
• D5NS (5% dextrose in normal saline)

• Lipids
– Lipid emulsions supply essential fatty acids
– Significant source of energy
– 10%, 20%, and 30% solutions: 1.1, 2.0, and
2.9 or 3.0 kcal/mL, respectively
• Fluids and electrolytes
– Patient’s fluid needs adjusted according to
daily fluid losses and hydration assessment

• Fluids and electrolytes
– Electrolytes: sodium, potassium, chloride,
calcium, magnesium, phosphate
– Electrolyte content measured in
milliequivalents (mEq)
• Vitamins and trace minerals
– Why are preparations available that do not
include vitamin K?

• Medications
– Occasionally added directly to parenteral
solutions or infused through a separate port in
the catheter (piggyback)
• Parenteral formulations
– Total nutrient admixture (TNA): 3-in-1 solution
• Contains dextrose, amino acids, and lipids

• Parenteral formulations
– 2-in-1 solution
• Contains dextrose and amino acids
• Lipid emulsion is administered separately
– Box 15-15 walks through calculations
• Osmolarity
– Components contributing most to osmolarity:
amino acids, dextrose, and electrolytes

• Administering parenteral nutrition
– Nutrition support teams
• Physicians, nurses, dietitians, and pharmacists
– Insertion and care of intravenous catheters
• Peripheral vein placement: skilled nurse
• Central vein placement: only qualified physicians
• Patient may be awake and given local anesthesia
• To relieve apprehension, explain procedure
beforehand

Parenteral Nutrition: Administering
• Insertion and care of intravenous
catheters
– What are ways to reduce the risk of
complications?
• Administration of parenteral solutions
– Method used to initiate and advance depends
on the patient’s condition and the potential for
complications
– Continuous vs. cyclic parenteral nutrition

Parenteral Nutrition: Administering
• Discontinuing parenteral nutrition
– Patient must have adequate GI function and
minimal risk for aspiration
– Discontinued when 60% to 75% of nutrient
needs provided by other means
– Suppressed appetite can make transition to
an oral diet difficult

• Managing metabolic complications
– Hyperglycemia
• Provide insulin along with parenteral solutions
• Avoid overfeeding or overly rapid infusion rates
• Restrict the amount of dextrose in the solution
– Hypoglycemia
• Taper off over infusions over several hours before
discontinuation

Parenteral Nutrition: Managing Metabolic
Complications (cont’d.)
• Hypertriglyceridemia
– Blood triglyceride levels >400 mg/dL: reduce
or stop lipid infusions
• Refeeding syndrome
– Initiate at ½ energy needs; advance slowly
– Monitor electrolyte and glucose levels when
malnourished patients begin receiving
nutrition support

• Liver disease
– Avoid giving the patient excess energy,
dextrose, or lipids, which promote fat
deposition in the liver
– Monitor enzyme levels weekly

• Gallbladder disease
– Possible prevention: initiate oral feedings
before problem occurs
– Treatment: medications, gallbladder removal
• Metabolic bone disease
– Possible interventions: PN adjustments,
nutrient supplements, medications, and
physical activity

Nutrition Support at Home
• Candidates for home nutrition support
– Home enteral nutrition
• Individuals who have disorders preventing food
from reaching the intestines or interfering with
nutrient absorption
– Home parenteral nutrition
• Individuals who have disorders severely impeding
nutrient absorption or interfering with intestinal
motility

Nutrition Support at Home (cont’d.)
• Planning home nutrition care
– Home enteral nutrition
• Access sites
• Administration methods
• Formulas
– Home parenteral nutrition
• TPN with catheter exiting through chest wall
• Solutions

Nutrition Support at Home (cont’d.)
• Quality-of-life issues
– Lifestyle adjustments
– Sleep disturbances
– Social implications
– Support groups and counseling

Nutrition in Practice:
Inborn Errors of Metabolism
• Role of nutrition therapy in treatment
• Role of other treatments
• Phenylketonuria
– Diagnosis: infant screening
– Nutrition therapy: phenylalanine restriction
with adequate tyrosine
• Galactosemia
– Nutrition therapy: galactose restriction

Chapter 15 Enteral and Parenteral Nutrition Support

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Chapter 15 Enteral and Parenteral Nutrition Support

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