Enteral Nutrition

NFSC 370

McCafferty

A. Definition: Utilization of the GI tract to supply nutrients

B. Preferred over parenteral nutrition:

C. Indications for use

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D. Contraindications for use

Types of Formulas1. Standard/Intact/Polymeric Formulas

Complete macronutrient molecules:

Pt. must be able to digest/absorb nutrients

2. Hydrolyzed (Elemental) Formulas

Low fat or MCT Low residue

3. Modular Formulas e.g. Polycose, Promod

Can be added to existing enteral formula to modify its composition

Can be combined together to create a highly individualized formula (rare)

Formula Composition1. Kcalories

Standard – Concentrated –

2. Residue: contributes to fecal bulk Low residue formula:

3. Fiber

• Fuel:

4. Osmolality: concentration of particles in a solution (mOsm/kg) Osmolality of blood – Isotonic solution: Hypertonic solution:

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Cost: Standard formulas are cheapest.

Formula Selection

Routes of Administration

A. Nasogastric (NG)Passage of the feeding tube transnasally into the stomach

1. Advantages

a.

b.

2. Disadvantages

a. Potentially aspirated:

b. Patient can pull out the tube

c. Nose and esophagus can become irritated

d. Cosmetically unattractive

B. Nasoduodenal/Nasojejunal: Passed nasogastrically into stomach, migrate to

small bowel

1. Advantages

a.

b.

2. Disadvantages

a.

b. Limits choice of formulas:

c. Increased chance of hypoglycemia (as in dumping syndrome)

d. Patient can pull out the tube

e. Nose and esophagus can become irritated

f. Cosmetically unattractive

C. Gastrostomy (PEG, G-tube) – Endoscopically placed into stomach, then brought out through abdominal wall (PEG) or surgically placed (GT)

More permanent – for use when TF will be long-term or if tube can’t be passed 2’obstruction, etc.

1. Advantages

a.

b.

c.

2. Disadvantages

a.

b.

c.

D. Jejunostomy (PEJ, J-Tube)

1. Advantages

a.

b.

c.

2. Disadvantages

a. Can’t recannulate if the tube comes out

b. Penetrates peritoneum; source of infection

Formula Delivery

** Head of bed should be elevated 300 during and after TF administration to minimize risk of aspiration.

1. Bolus feeding or “meal infusion”

a.

b.

c.

d.

e.

f.

2. Continuous infusiona. Continuous delivery in controlled amounts over

24hours

b. Controlled delivery for enhanced GI tolerance (not much difference if delivered to stomach with functioning pylorus)

c. Begin isotonic formula at FS at a slow rate

d. rate as tolerance allows in stepwise increments until nutrient goals are met

e. Gastric residuals

f. Gravity vs. Pump Gravity method less accurate

• More attention must be paid to tube size, location, and patient mobility.

• Not advisable with closed system delivery Pump – more accurate, enhances GI tolerance,

more expensive

3. Cyclic feedinga. E.g. b. c.

4. All feedings: Supplemental Watera. Water used to flush feeding tube before and

after feeding/when tube/bag are changedb. Pay attention to hydration status of pt.c. Total water should be

d. Typical TF formula is

5. Drugs via Tubea. Can cause drug-nutrient interactions

b. Formula can affect drug absorption

c. Some drugs can clog tubes

Tube Feeding Complications

1. Failure to achieve/maintain adequate nutrition status

a. Check calculations

b.

c.

d.

e. Monitor pt. tolerance of TF

2. Diarrhea

a. May be related to formula, illness, or other treatments

b.

c. Bacterial contamination

d. Infusion rate too high –

e. Hypertonic formula –

f. Malnutrition/low serum albumin – slow rate or continuous drip.

3. Aspiration

4. Nausea

5. Malabsorption

6. Clogged feeding tube

7. Fluid/lyte imbalances

8. Hyperglycemia

9. Refeeding Syndrome (to be discussed in “Stress” chapter)

Calculations1. Caloric Requirements of Patient

H-B/Long’s method or kcals/kg

2. Protein Requirements

a. _____g/kg current weight (or adjusted weight )

b. Kcal:N ratio

200:1 not stress, hospitalized

150:1 moderate stress

100:1 severe stress, such as burns, sepsis, head injury

3. Water Requirements 1ml/kcal, or 30-35ml/kg/day minimum (adults

only).

4. Calculating Tube Feeding: (refer to handout)

Charting

Enteral Order: Date, product, rate, strength, additional fluid, IV fluids if applicable

Nutritional Provisions: Kcals, protein, and fluid provided

Labs: Albumin, BUN, Na, and Glucose

Nutritional Needs: Kcals, protein, and fluids(as calculated with Harris-Benedict equation, etc.)

Assessment: Albumin and wt. status, hydration status, appropriateness/adequacy of enteral order, tolerance, nutrition status of patient.