Download Total Parenteral Nutrition

ENTERAL and
PARENTERAL FEEDING
Mylin G. Abalus
NUTN 204 Lecturer
OBJECTIVES
LESSON OVERVIEW
Enteral Nutrition
 Form of feeding that brings nutrients
directly into the digestive tract
1. Oral feeding
2. Tube feeding- feeding by tube directly into
the stomach or intensive or via a vein
Enteral Nutrition
 Indicated for patients who have a
functioning GIT but can’t ingest enough
nutrients orally
Advantages:
Better preservation of the structure and function of GIT
Lower cost
Fewer complications, particularly infections
Indications:
Prolonged anorexia
Severe protein-energy undernutrition
Coma or depressed sensorium
Liver failure
Inability to take oral feedings
Critical illnesses
Malabsorption problems
Types of Feeding Tubes
 Nasogastric (NG) tube
 inserted through the nose and into the
stomach and small intestine
 For periods that do not exceed 6 weeks
 Percutaneous Endoscopic Gastrostomy
(PEG) tube
 For periods > 6 weeks
 Opening called an “ostomy” is needed
(esophagostomy, gastrostomy, jejunostomy)
Types of Enteral Formulas
 POLYMERIC FORMULA
Commercially prepared formulas that provides
complete, balance diet
1-2 calories/ml
Contains proteins, carbohydrates, and fats
Requires digestion
Blenderized food and milk-based or lactose free
commercial formula
Types of Enteral Formulas
 ELEMENTAL or HYDROLYZED FORMULAS
Formula containing products of digestion of
proteins, carbohydrates and fats
Used for clients who have difficulty digesting
food
Provide 1 cal/ ml; lactose-free
Expensive and usually unnecessary
e.g. amino acid formula, calorie- and proteindense formula, restricted, fiber-enriched
formula
Types of Enteral Formulas
 MODULAR FORMULAS (Feeding modules)
Provides 3.8- 4 cal/ml
Can be used as supplements to other formulas
or for developing customized formulas for
certain clients (e.g. burn patients)
Usually used in acute setting and for short
period of time (e.g. renal failure, respiratory
failure, liver failure)
May contain specific nutrient; used to treat
specific deficiency or combines with other
formulas
Three Methods of Administering
Tube Feedings
 Intermittent
Administering tube feedings usually at night;
solid foods eaten during the day
 Bolus
Daily calorie needs are divided into 6
servings/day (< 400 ml); given over 15 mins
followed by 25-60 ml of water
 Continuous
Feedings are administered by a continuous
pump; 16- to 24-hour period; initially at a rate
of 30-50 ml/per
Guidelines in Administering
Tube Feedings
 Nasogastric or nasoduodenal tube feeding
NGT feeding often causes diarrhea
Usually started with small amounts of dilute
preparations
Solution may be given undiluted at 50 ml/hour
Water boluses may be given
Note: Higher caloric formula may cause decreased
gastric emptying  higher residual than more dilute
formula
 Jejunostomy tube feeding
Requires greater dilution and smaller volumes
Feeding usually begins at < 0.5 kcal/ml and a rate of 25
ml/h
Concentrations and volumes is increased after few
days
Complications of Enteral Tube
Nutrition
PROBLEM
CAUSE
EFFECT
1. Presence of tube
Tube irritates tissues Damage to the
causing them to
nose, pharynx or
erode
esophagus
2. Blockage of tube
lumen
Thick feedings or
pills can block the
lumen
Inadequate feeding
3. Misplacement of
nasogastric tube
intracranially
Tube may be
misplaced
intracranially if the
cribriform plate is
disrupted by severe
facial trauma
Brain trauma,
infection
Complications of Enteral Tube
Nutrition
PROBLEM
CAUSE
EFFECT
4. Misplacement of
naso- or orogastric
tube in the
tracheobronchial
tree
Responsive patients- Pneumonia
cough and gag
Obtunded patientsmay have few
immediate
symptoms
5. Dislodgement of
gastrostomy or
jejunostomy tube
Tube may be
displaced into the
peritoneal cavity
Peritonitis
Complications of Enteral Tube
Nutrition
PROBLEM
CAUSE
EFFECT
6. Intolerance of
one of the formula’s
main nutrient
components
*usually occurs with
bolus feedings
*lactose
Diarrhea, GI
discomfort, nausea,
vomiting
7. Osmotic diarrhea
High osmolality of
the solution
Weakness, diarrhea
*Sorbitol- often
contained in liquid
drug preparations
*Clostridium difficile
8. Nutrient
imbalances
Specific formulas
Electrolytes
disturbances,
hyperglycemia,
Complications of Enteral Tube
Nutrition
PROBLEM
9. Reflux of
solutions
CAUSE
Clogged tube or
tube may be pulled
out
EFFECT
ASPIRATION
Parenteral Nutrition
 Provision of nutrients intravenously
 Used if GIT is not functional or normal feeding is
not adequate
 Compared with enteral feeding, it causes more
complications, does not preserve GIT structure and
function and more expensive
 Solutions- prescribed by physician and dietitian and
prepared by pharmacist
 Administered via CENTRAL or PERIPHERAL VEIN
Parenteral Nutrition
Peripheral Vein
 2 weeks or less
Central Vein
 > 2 weeks
 Subclavian or superior
vena cava is used
Indications:
Some stages of Crohn’s disease or ulcerative colitis
Bowel obstruction
Certain pediatric GI disorders (congenital anomalies, prolonged
diarrhea)
Short bowel syndrome
Types of Parenteral Nutrition
1. Partial Parenteral Nutrition
 Supplies only part of daily nutritional
requirements, supplementing oral intake
 Dextrose or amino acids solutions
2. Total Parenteral Nutrition
(Hyperalimentation)


Supplies all daily nutritional requirements
TPN solutions are highly concentrationcentral vein is used
Parenteral Nutrition Content
water
30-40 ml/kg/day
energy
30-60 kcal/kg/day
(depending on energy
expenditure)
Amino acids
1-2 g/kg/day
Essential fatty acids
Vitamins
minerals
Standard TPN solution- 2 L
Most calories are supplied by CHO (25% dextrose)
May also have lipid emulsions to supply essential fatty acids
and triglycerides
20-30% of total cal supplied from lipids
Electrolytes may be added
Modified based on results, d/o
Parenteral Nutrition Solutions
 Reduced protein content and high
percentage of essential amino acidrenal failure or liver failure
 Limited volume (liquid) intake- heart or
kidney failure
 Lipid emulsion (provides non-CHON
calories minimize CO2 production by CHO
metabolism)- respiratory failure
Guidelines in Caring for Patient
having Parenteral Nutrition
 Strict sterile technique during insertion and
maintenance of central venous catheter
 TPN line should not be used for any other
purpose
 External tubing should be change every 24
hours
 Dressing should be kept sterile and
changed every 48 h using strict sterile
technique
Guidelines in Administering
Parenteral Nutrition
 Solution is started slowly at 50% calculated
requirements + 5% dextrose
 Energy and nitrogen given simultaneously
 Amount of regular insulin (added directly to
the TPN solution) depends on the serum
glucose level (e.g. level is normal; 25% dextrose=
5-10 units of regular insulin)
Guidelines in Caring for Patient
having Parenteral Nutrition
 Monitor weight, CBC, electrolytes and BUN
 Serum glucose monitored every 6 h until




stable
Monitor intake and output
Monitor liver function test
Measure plasma CHONs (albumin),
prothrombine time, plasma and urine
osmolality, Ca, Mg and phosphate twice a
week
Full nutritional assessment (BMI) every 2
weeks
Complications of
Parenteral Nutrition
 Catheter related sepsis
 Phlebitis/thrombosis
 Glucose abnormalities
 Hepatic complications
 Abnormalities of serum electrolytes and
minerals
 Volume overload
 Bone demineralization
 Gallbladder complications