NHHC chapter 15 ppt

Nutrition for Health and Health Care, 5th Edition
DeBruyne ■ Pinna © Cengage Learning 2014
Enteral and Parenteral
Nutrition Support
Chapter 15

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
• Avoid stress, complications, and expense of tube
feedings
– “How To” Help Patients Improve Intakes with
Oral Supplements

Enteral Nutrition (cont’d.)
• Situations warranting 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

• Situations warranting 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 (Glossary)
– Factors in selecting feeding route
• Patient’s medical condition
• Expected duration of tube feeding
• Potential complications of a particular route

• Gastrointestinal access
– Tube feeding: less than four 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)

• Gastrointestinal access
– Infants
• Orogastric placement: sometimes preferred over
transnasal routes
– Direct route to stomach or intestine conditions
• Tube feeding longer than four weeks
• Inaccessible nasointestinal route
• Types of direct routes: enterostomy, gastrostomy,
or jejunostomy

• Selecting a feeding route
– Based on duration
• Transnasal access for less than four weeks and
enterostomies for longer periods
– Gastric feedings (nasogastric and
gastrostomy routes)
• Preferred whenever possible
• Avoided in patients at high risk of aspiration

• Advantages and disadvantages
(Table 15-1)
• Feeding tubes
– Soft, flexible materials
– Tube selection factors
• Patient’s age and size, the feeding route, and the
formula’s viscosity

• Feeding tubes
– Outer diameter
• 1 French = 1/3 mm; 12 French = 4 mm
– Double-lumen tubes
• Intestinal feedings and gastric decompression

• Enteral formulas (Appendix G)
– Main types
• Standard formulas: patient can digest and absorb
nutrients without difficulty
• Elemental formulas: patients who have
compromised digestive or absorptive functions

• Enteral formulas
– Main types
• Specialized formulas: meet the specific nutrient
needs of patients with particular illnesses
• Modular formulas: patients who require specific
nutrient combinations to treat their illnesses

– Macronutrient composition
• Protein: 10 to 25 percent of total kcalories
• Carbohydrate: 30 to 60 percent of kcalories
• Fat: 10 to 45 percent of kcalories
– Energy density
• 1.0 to 2.0 kcalories per milliliter of fluid
– Fiber content
• Formulas with or without fiber

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

– Factors influencing formula selection
(Figure 15-3)
• Nutrient and energy needs
• Fluid requirements
• Need for fiber modifications
• Individual tolerances (food allergies and
sensitivities)

– Safe handling
• Facility-specific protocols
• Open feeding system vs. closed feeding system
• What steps can reduce the risk of formula
contamination when using open feeding systems?

• Administration of tube feedings
– Preparation
• Fully discuss the procedure with the patient and
family members
• Tube placement: X-rays to verify before initiating
feeding
– “How To” Help Patients Cope with Tube
Feedings

– Preparation
• Reduce risk of aspiration: elevate patient’s upper
body during and following feeding
– Formula delivery methods
• Intermittent feedings vs. continuous feedings
– “How To” Plan a Tube Feeding Schedule

– Recommendations for delivery: adults
• Formulas: typically provided in full-strength
• Intermittent feedings: start with 60 to 120 milliliters
at the initial feeding; increased by 60 to 120
milliliters at each feeding until reaching the goal
volume
• Continuous feedings: start at rates of 40 to 60
milliliters/hour; raised by 20 milliliters/hour until
reaching the goal rate

– Recommendations for delivery: adults
• If the patient cannot tolerate an increased delivery
rate: feeding rate slowed until the person adapts
• Better tolerated with slower delivery rates:
critically ill patients; concentrated formulas used; or
patients who have undergone an extended period
of bowel rest

– Meeting water needs
• Adult requirements: 2000 milliliters per day
• Enteral formulas: 70 to 85 percent water
(700 to 850 milliliters of water per liter)
• Estimating fluid intakes: also account for water
flushes

– Checking the gastric residual volume
• Volume of formula and GI secretions remaining in
the stomach after feeding

• Medication delivery during tube feedings
– Why are continuous feedings stopped prior to
and after medication administration?
– Diarrhea
• Medications: a major cause
• Dilution of hypertonic medications: may be helpful
– “How To” Administer Medications to Patients
Receiving Tube Feedings

• Tube feeding complications (Table 15-2)
– 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
• Case Study – Injured Hiker Requiring
Enteral Nutrition Support

Parenteral Nutrition
• Conditions for parenteral nutrition
– Intestinal obstructions or fistulas
– Paralytic ileus (intestinal paralysis)
– Short bowel syndrome: substantial portion of
the small intestine has been removed
– Intractable vomiting or diarrhea

Parenteral Nutrition (cont’d.)
• Conditions for parenteral nutrition
– Severe gastrointestinal bleeding
– Bone marrow transplants
– Severe malnutrition and intolerance to enteral
nutrition
• Venous access
– Categories: peripheral veins or central veins

• Venous access
– Peripheral parenteral nutrition (PPN)
• Nutrients via peripheral veins only
• What can be done to prevent phlebitis?
• “How To” Express the Osmolar Concentration of a
Solution
• Patients requiring 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

• Parenteral solutions
– Often prepared by pharmacies located within
health care institutions (Figure 15-5)
• Customize the solutions
• Limited shelf life

• Composition of parenteral solutions
– Contain all essential amino acids
• Concentrations: 3.5 to 20 percent
– Carbohydrate
• Main source of energy: glucose (dextrose
monohydrate)
• Concentration examples:
D5W (5 percent dextrose in water)
D5NS (5 percent dextrose in normal saline)

– Lipids
• Lipid emulsions: supply essential fatty acids;
significant source of energy
• 10, 20, and 30 percent solutions: 1.1, 2.0, and 3.0
kcalories per milliliter, respectively
– Fluids and electrolytes
• Patient’s fluid needs adjusted according to daily
fluid losses and hydration assessment

– Fluids and electrolytes
• Electrolytes: calcium, magnesium, phosphorus,
sodium, potassium, and chloride
• Electrolyte content: measured in milliequivalents
– 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: administered separately
– “How To” Calculate the Macronutrient and
Energy Content of a Parenteral Solution

• Osmolarity
– TPN solutions: may be as nutrient dense as
needed
• Components contributing 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: awake or given local anesthetic
• Relieve apprehension: explain procedure
beforehand

– Insertion and care of intravenous catheters
• What are ways to reduce the risk of complications?
– Methods used to initiate and advance
parenteral nutrition
• Depends on the patient’s condition and the
potential for complications
• Continuous vs. cyclic parenteral nutrition

– Discontinuing intravenous infusions
• Patient must have adequate GI function
• Suppressed appetite: transition to an oral diet may
be difficult

• Managing metabolic complications
– Hyperglycemia
• Provide insulin along with parenteral solutions or
restrict the amount of dextrose in parenteral
solutions
– Hypoglycemia
• Taper off over infusions over several hours before
discontinuation

– Hypertriglyceridemia
• Blood triglyceride levels exceeding 500 milligrams
per deciliter: reduce or stop lipid infusions
– Refeeding syndrome
• Start parenteral infusions slowly and carefully
• Monitor electrolyte and glucose levels when
malnourished patients begin receiving nutrition
support

– Liver disease
• Minimize risk: avoid giving the patient excess
energy, dextrose, or lipids, which promote fat
deposition in the liver
– Gallbladder disease
• Possible prevention: initiate oral feedings before
problem occurs

– Metabolic bone disease
• Intervention varies among patients: dietary
adjustments, nutrient supplements, medications,
and physical activity
• Case Study – Patient with Intestinal
Disease Requiring Parenteral Nutrition

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
– Decisions required
• Access sites
• Formulas
• Nutrient deliver methods
• Quality of life issues
– Lifestyle adjustments and social implications
– Support groups and counseling

NHHC chapter 15 ppt

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