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Enteral and Parenteral Nutrition Support Methods
- 1. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral and Parenteral Nutrition Support Chapter 15
- 2. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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?
- 3. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014
- 4. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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
- 5. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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
- 6. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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?
- 7. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Tube feeding routes (Glossary) – Factors in selecting feeding route • Patient’s medical condition • Expected duration of tube feeding • Potential complications of a particular route
- 8. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014
- 9. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014
- 10. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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)
- 11. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 12. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 13. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 14. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Feeding tubes – Outer diameter • 1 French = 1/3 mm; 12 French = 4 mm – Double-lumen tubes • Intestinal feedings and gastric decompression
- 15. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 16. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 17. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Enteral formulas – 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
- 18. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Enteral formulas – 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
- 19. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Enteral formulas – Factors influencing formula selection (Figure 15-3) • Nutrient and energy needs • Fluid requirements • Need for fiber modifications • Individual tolerances (food allergies and sensitivities)
- 20. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Enteral formulas – 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?
- 21. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 22. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Administration of 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
- 23. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Administration of tube feedings – 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
- 24. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Administration of tube feedings – 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
- 25. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Administration of tube feedings – 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
- 26. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Administration of tube feedings – Checking the gastric residual volume • Volume of formula and GI secretions remaining in the stomach after feeding
- 27. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 28. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • Tube feeding complications (Table 15-2) – Many complications preventable by appropriate selections • Feeding route • Formula • Delivery method
- 29. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Enteral Nutrition (cont’d.) • 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
- 30. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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
- 31. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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
- 32. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • 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
- 33. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Venous access – Total parenteral nutrition (TPN) • Nutrients delivered via central veins • Preferred for cases requiring nutrient-dense solutions or long-term parenteral nutrition
- 34. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014
- 35. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Parenteral solutions – Often prepared by pharmacies located within health care institutions (Figure 15-5) • Customize the solutions • Limited shelf life
- 36. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • 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)
- 37. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Composition of parenteral solutions – 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
- 38. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Composition of parenteral solutions – 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?
- 39. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • 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
- 40. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • 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
- 41. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • 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
- 42. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Administering parenteral nutrition – 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
- 43. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014
- 44. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Administering parenteral nutrition – 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
- 45. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Administering parenteral nutrition – Discontinuing intravenous infusions • Patient must have adequate GI function • Suppressed appetite: transition to an oral diet may be difficult
- 46. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • 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
- 47. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Managing metabolic complications – 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
- 48. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Managing metabolic complications – 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
- 49. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 Parenteral Nutrition (cont’d.) • Managing metabolic complications – Metabolic bone disease • Intervention varies among patients: dietary adjustments, nutrient supplements, medications, and physical activity • Case Study – Patient with Intestinal Disease Requiring Parenteral Nutrition
- 50. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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
- 51. Nutrition for Health and Health Care, 5th Edition DeBruyne ■ Pinna © Cengage Learning 2014 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
Notas del editor
- Figure 15-1 Selecting a Feeding Route
- Figure 15-2 Tube Feeding Routes Transnasal feeding tube placements
- Figure 15-2 Tube Feeding Routes (cont’d.) Enterostomies
- Figure 15-4 Accessing Central Veins for Total Parenteral Nutrition Traditionally, central catheters enter the circulation at the right subclavian vein and are threaded into the superior vena cava with the tip of the catheter lying close to the heart. Sometimes catheters are threaded into the superior vena cava from the left subclavian vein, the internal jugular vein, or the external jugular vein. Peripherally inserted central catheters usually enter the circulation at the basilic or cephalic vein and are guided up toward the heart so that the catheter tip rests in the superior vena cava.
- Table 15-3 Potential Complications of Parenteral Nutrition