1. FEEDING PATIENTS
THERAPEUTIC DIETS
By ZIA IMRAN
2015 year 1

2. © 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

3. © 2007 Thomson - Wadsworth

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

5. Parenteral Nutrition:
Parenteral nutrition:
The delivery of
nutrients by vein.

6. 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

7. 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)

8. 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

9. 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

10. © 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)

11. 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.

12. 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.

13. 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.

14. 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.

15. 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

16. 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

17. • 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.

18. • 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

19. • 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

20. 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.

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

22. 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.

23. 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.

24. 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.

25. © 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.

26. 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.

27. Parenteral Nutrition Support
© 2007 Thomson - Wadsworth

28. © 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

29. © 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

30. © 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

31. © 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

32. © 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

33. © 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

34. THERAPEUTIC DIETS
Altered Consistency Diets.
1. Clear liquid diet
2. Full liquid diet
3. Pureed diet
4. Dysphagia diet
5. Soft diet

35. • 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.

36. CLEAR LIQUID FOODS
FULL LIQUID FOODS

37. SOFT DIET FOODS
BLENDERIZED FOODS

38. 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.

39. • 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.

41. 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.

43. 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).

44. 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.

45. 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.

46. • 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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